Patient Management

A $32$-year-old woman is admitted to the hospital with a newly diagnosed acute pulmonary embolism. She is hemodynamically stable and has no significant past medical history. Her only home medication is an oral contraceptive pill. Her body mass index is $24$ kg/m $^2$, and her serum creatinine is $0.7$ mg/dL. The medical team initiates therapeutic-dose subcutaneous enoxaparin. They plan to transition her to an oral anticoagulant prior to discharge. During the initial period while she is receiving solely enoxaparin, which of the following is the most appropriate strategy for monitoring the anticoagulant effect of this medication?

A 55-year-old woman is preparing for discharge following an admission for a non-ST-segment elevation myocardial infarction (NSTEMI). She underwent a successful percutaneous coronary intervention with the placement of a drug-eluting stent. Her past medical history includes hypertension and hyperlipidemia. Her vitals are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $122/78\text{ mmHg}$, pulse $68/\text{min}$, and respiratory rate $14/\text{min}$. An echocardiogram demonstrates a left ventricular ejection fraction of $55\%$. In addition to dual antiplatelet therapy with aspirin and clopidogrel, which of the following pharmacologic interventions should be included in her discharge regimen to provide a long-term mortality benefit? (Select all that apply)

A 75-year-old man is hospitalized for his fourth exacerbation of heart failure in the past 6 months. He has New York Heart Association (NYHA) Class IV heart failure with a left ventricular ejection fraction of 15%. His home medications include maximum tolerated doses of carvedilol, sacubitril-valsartan, spironolactone, and dapagliflozin. During this admission, he required a continuous milrinone infusion to relieve severe dyspnea at rest and maintain adequate end-organ perfusion. Over the past 48 hours, attempts to wean the milrinone have repeatedly resulted in worsening respiratory distress and an acute rise in his serum creatinine from 1.4 mg/dL to 2.9 mg/dL. He has been evaluated by the advanced heart failure team and is not a candidate for a ventricular assist device or cardiac transplantation due to age and multiple comorbidities.

During a family meeting, the patient states, "I am tired of being in the hospital. I just want to go home and be comfortable. I do not want any more aggressive treatments or to be readmitted." He lives in a single-story home with his daughter, who is willing and able to provide 24-hour care.

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

Pair each of the following ambulatory patient scenarios with the single most appropriate, evidence-based preventive screening or immunization.

Match each clinical presentation of a patient with severe or resistant hypertension to the most appropriate next diagnostic test in their workup sequence.

A 28-year-old man is brought to the emergency department by paramedics following an altercation during which he sustained multiple stab wounds to the left hemithorax and mid-abdomen. On arrival, he is extremely agitated, diaphoretic, and confused. Vital signs show a temperature of $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), blood pressure of $68/40\text{ mm Hg}$, pulse of $145\text{/min}$, and respiratory rate of $38\text{/min}$. Oxygen saturation is $84\%$ on high-flow oxygen via a nonrebreather mask. Physical examination reveals markedly distended neck veins, tracheal deviation to the right, and absent breath sounds over the left lung fields. The abdomen is rigid with severe diffuse tenderness to palpation. Capillary refill is delayed.

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

A 61-year-old man presents to the ambulatory clinic to establish care. He has not seen a physician in over 15 years. He feels well and has no acute complaints. His only past medical history is hyperlipidemia, for which he previously took a medication but stopped 10 years ago. He currently takes no medications. He smoked one pack of cigarettes daily from age 20 to 50 but quit 11 years ago (30 pack-year history). He drinks 1 to 2 beers on weekends. Family history is notable for a father who died of a myocardial infarction at age 78. Vital signs include blood pressure 138/86 mmHg, heart rate 72/min, respiratory rate 14/min, and BMI 27 kg/m². Physical examination is unremarkable. Which of the following preventive screening interventions are indicated for this patient at this visit according to current guidelines? (Select all that apply)

A 42-year-old man presents to the emergency department after a single episode of vomiting dark, coffee-ground-like material earlier this morning. He also reports mild, burning epigastric pain that started a week ago. He denies melena, hematochezia, lightheadedness, or syncope. He has no prior medical conditions and occasionally takes over-the-counter ibuprofen for back pain. He lives with his wife, who drove him to the hospital, and they reside 10 minutes away.

On physical examination, his temperature is 37.0°C (98.6°F), blood pressure is 128/82 mm Hg, pulse is 78/min, and respiratory rate is 14/min. Orthostatic vital signs show no significant changes. The abdomen is soft with mild epigastric tenderness to deep palpation, but there is no guarding or rebound. Digital rectal examination reveals brown stool that is guaiac positive.

Laboratory results are as follows:

Hemoglobin: 14.8 g/dL
Platelet count: 240,000/mm³
Blood urea nitrogen: 14 mg/dL
Serum creatinine: 0.8 mg/dL
Liver function tests: Normal
Prothrombin time: 11 sec (INR 1.0)

The patient is observed in the emergency department for 4 hours. He has no further episodes of emesis, his vital signs remain stable, and he tolerates oral liquids without difficulty.

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

A 34-year-old man is brought to the emergency department by paramedics after falling approximately 30 feet (9 meters) from a scaffolding at a construction site. On arrival, he is moaning incomprehensibly, does not open his eyes to painful stimuli, and exhibits abnormal flexion posturing. He has pooled blood and secretions in his oropharynx. His respiratory rate is 8/min and shallow. Blood pressure is 78/40 mmHg, and heart rate is 142/min. Oxygen saturation is 84% on room air. Physical examination reveals a large scalp hematoma and an obviously deformed, swollen right thigh. Which of the following interventions should be ordered simultaneously as the most appropriate immediate next steps in management? (Select two)

A $29$-year-old woman is evaluated in the clinic for a follow-up visit. Six weeks ago, she was diagnosed with Graves disease after presenting with a $3$-month history of weight loss, heat intolerance, and palpitations. At that time, laboratory studies showed a markedly suppressed thyroid-stimulating hormone (TSH) level and elevated free thyroxine (T4) and total triiodothyronine (T3) levels. She was started on methimazole $20$ mg daily.

Today, she reports feeling much better. She has regained $2$ kg ($4.4$ lbs) and her palpitations and heat intolerance have resolved. Her heart rate is $72$/min and blood pressure is $112/70$ mm Hg. Physical examination shows a small, non-tender, symmetric goiter. There is no tremor or exophthalmos.

Repeat laboratory studies show:
Thyroid-stimulating hormone (TSH): $<0.01$ $\mu$ U/mL (reference: $0.4-4.2$ $\mu$ U/mL)
Free thyroxine (T4): $1.2$ ng/dL (reference: $0.8-1.8$ ng/dL)
Total triiodothyronine (T3): $130$ ng/dL (reference: $80-200$ ng/dL)

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

A 71-year-old man is hospitalized for the third time in two months due to complications of end-stage liver disease, including refractory ascites and recurrent hepatic encephalopathy. Upon admission two days ago, he was confused and asterixis was present. Following aggressive treatment with lactulose and rifaximin, his mental status has returned to baseline. During morning rounds, the patient calmly states that he is exhausted by the frequent hospitalizations and poor quality of life. He expresses a desire to stop all liver-directed therapies, avoid any future intensive care admissions, and focus exclusively on comfort.

His daughter, who is his legally appointed healthcare proxy, is at the bedside and becomes very upset. She tells the physician, "You cannot listen to him! He was completely delirious yesterday, which proves he is legally incompetent to make this choice. As his proxy, I demand that you continue full medical treatment."

The physician evaluates the patient and finds him to be fully oriented to person, place, time, and situation. The patient accurately describes his medical condition, understands that refusing further treatment will lead to his death, and clearly explains that he values comfort over prolonged suffering.

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

A 62-year-old man comes to the clinic to discuss the results of a recent ambulatory electrocardiogram, which confirmed newly diagnosed atrial fibrillation. His past medical history is significant for major depressive disorder treated with fluoxetine, and severe persistent asthma treated with an inhaled corticosteroid and formoterol. The physician recommends starting an oral anticoagulant to reduce the risk of stroke. The patient becomes visibly anxious and states, "I read online that those blood thinners can make you bleed to death. I do not want to take them. Instead, I want to manage this naturally and start taking an over-the-counter St. John's wort supplement, which my friend said is great for your heart and mood." Which of the following is the most appropriate next step in counseling this patient?

An 81-year-old male is brought to the emergency department following a massive ischemic stroke. He is currently unresponsive, intubated, and has been formally determined to lack decision-making capacity. The care team must urgently establish a goals-of-care plan to determine whether to pursue aggressive life-prolonging interventions or transition to palliative comfort measures. A chart review reveals that no advance directive, living will, or designated healthcare power of attorney is on file. Multiple relatives are present in the waiting room and are offering conflicting opinions regarding the patient's likely wishes. To proceed legally and ethically, the attending physician must identify the appropriate surrogate decision-maker. Arrange the following family members in the standard legal hierarchy of default surrogate decision-makers, from highest priority (first) to lowest priority (last).

A 35-year-old man comes to the clinic for a routine wellness examination. He was diagnosed with HIV 5 years ago. He is highly adherent to his daily antiretroviral therapy regimen, which consists of bictegravir, emtricitabine, and tenofovir alafenamide. He feels well and reports no fatigue, weight loss, or recent illnesses. He identifies as a man who has sex with men and is in a monogamous relationship. He does not use tobacco, alcohol, or illicit drugs.

His most recent laboratory studies from two weeks ago show a CD4 T-lymphocyte count of 720 cells/mm³ and an undetectable HIV-1 viral load.

A review of his immunization record reveals the following:
- Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine: 1 dose received 4 years ago
- Hepatitis A and B vaccines: completed series 5 years ago; recent serology confirms robust immunity
- Human papillomavirus (HPV) vaccine: completed 3-dose series at age 24
- Quadrivalent meningococcal conjugate vaccine (MenACWY): completed a 2-dose primary series 3 years ago
- 20-valent pneumococcal conjugate vaccine (PCV20): 1 dose received 1 year ago

He had a documented case of chickenpox at age 6. His vital signs are within normal limits, and physical examination shows no abnormalities.

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

A 72-year-old woman arrives at the outpatient physician office for a routine wellness evaluation. She feels well and has no acute symptoms. Her medical history is significant for hypertension, hyperlipidemia, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy performed at age 45 for high-grade cervical intraepithelial neoplasia (CIN 3). She does not take hormone replacement therapy. Social history is notable for smoking 1.5 packs of cigarettes daily from age 18 until age 60 (63 pack-years); she has not smoked since. Her preventive health history includes a normal screening mammogram 10 months ago, a normal screening colonoscopy at age 66, and a dual-energy x-ray absorptiometry scan at age 65 that showed normal bone mineral density. Vital signs are within normal limits. Physical examination shows a well-appearing woman with no abnormalities.

Which of the following is the most appropriate indicated preventive screening test for this patient today?

A 72-year-old man with a history of hypertension, type 2 diabetes mellitus, and a recent transient ischemic attack (TIA) is evaluated via telehealth. He was recently diagnosed with paroxysmal atrial fibrillation and prescribed apixaban for stroke prophylaxis. During the visit, he reports he has not filled the prescription. He states, "I know I am at high risk for a stroke, and I know this drug prevents them. But my older brother was on a blood thinner, fell in his kitchen, and died from bleeding into his brain. I live alone, I have neuropathy in my feet, and I fall at least once a month. I've thought about it deeply, and I've decided that bleeding to death on the floor alone is a worse fate than a stroke. I am not taking it." The physician determines the patient is alert, fully oriented, and demonstrates a clear understanding of his diagnosis, the proposed treatment, and the consequences of his refusal.

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

A 58-year-old man presents to the clinic for a routine follow-up. His medical history is significant for severe chronic obstructive pulmonary disease, type 2 diabetes mellitus, and a seizure disorder. His current medications include inhaled tiotropium, oral theophylline, metformin, and levetiracetam. He has a 40-pack-year smoking history and currently smokes 1.5 packs of cigarettes daily. During the visit, the physician brings up smoking cessation. The patient sighs and states, 'I know I need to quit. I've been thinking about it a lot lately, and I want to try to stop in the next couple of months. I am just really worried about the withdrawal symptoms.' Which of the following is the most appropriate physician response or action regarding this patient's counseling and management?

A physician is counseling several patients in an outpatient clinic regarding lifestyle modifications. Match each patient's statement with the most appropriate physician counseling strategy based on the Transtheoretical Model of Change.

A 45-year-old man was recently diagnosed with type 2 diabetes mellitus. Match each of his statements regarding lifestyle modifications (which represent different stages of the transtheoretical model of change) with the most appropriate physician counseling strategy.

A physician is evaluating four different patients in an outpatient clinic. Each patient presents with a lifestyle modification challenge. Match each patient's statement (representing a specific stage in the Transtheoretical Model of Change) with the most appropriate physician communication strategy and response.