Patient Management

A 55-year-old man is evaluated in the intensive care unit (ICU) prior to withdrawal of life-sustaining treatment. He was admitted 14 days ago with severe acute respiratory distress syndrome (ARDS) secondary to viral pneumonia. Despite prone positioning and maximal medical therapy, his pulmonary function has irreversibly declined. He is currently intubated and mechanically ventilated. To manage severe ventilator dyssynchrony, he has been maintained on continuous intravenous infusions of propofol, fentanyl, and cisatracurium. Following multidisciplinary meetings, his wife, who is his designated healthcare proxy, decides to transition to comfort measures only. The medical team agrees that further aggressive interventions are futile, and the plan is to proceed with terminal extubation. His current vital signs are temperature 37.2°C (99.0°F), blood pressure 105/65 mm Hg, and heart rate 95/min.

Which of the following is the most appropriate next step in management regarding the patient's medication infusions?

A male patient, aged 74, is evaluated at home by the hospice interdisciplinary team. He has a history of metastatic colorectal carcinoma and transitioned to comfort-focused care three weeks ago. Over the past four days, he has become progressively somnolent, spending the vast majority of the day asleep. When gently awakened, he is oriented to person and appears comfortable, denying any pain, shortness of breath, hunger, or thirst. His spouse is visibly distraught and tearfully states, "He hasn't eaten anything solid since Tuesday and barely takes sips of water. We cannot just let him starve to death. Isn't there a way we can feed him or give him fluids?"

Physical examination reveals a frail, cachectic man appearing comfortable in bed. Vital signs show a blood pressure of $88/52 \text{ mmHg}$, heart rate of $110/\text{min}$, and respiratory rate of $14/\text{min}$. Mucous membranes are dry, and trace pedal edema is present.

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

A physician is evaluating several patients with varying degrees of readiness to adhere to medical advice. Based on the Transtheoretical Model of Change, match each patient statement regarding their health behavior to the most appropriate, stage-matched physician counseling strategy.

Match each ambulatory patient scenario with the single most appropriate, evidence-based preventive screening or immunization recommendation according to current guidelines.

Match each of the following complex ambulatory patient profiles with the single most appropriate, evidence-based preventive screening or immunization recommendation.

A 79-year-old man is evaluated during a home hospice visit. He has end-stage ischemic cardiomyopathy and was enrolled in hospice care one week ago. He spends most of the day in bed and experiences severe dyspnea and fatigue with minimal exertion. His medications include a continuous furosemide infusion and low-dose oral morphine for dyspnea. He has a cardiac resynchronization therapy defibrillator (CRT-D) that was implanted four years ago. His wife is his designated healthcare proxy. She expresses concern that the device might shock him when he is dying, which she fears would be painful and distressing. He is currently comfortable, with a heart rate of 78/min and blood pressure of 96/60 mmHg. Which of the following is the most appropriate next step in management regarding the patient's CRT-D?

An established 68-year-old female patient is seen for a health maintenance examination. She has a documented background of chronic obstructive pulmonary disease (COPD) managed with an inhaled corticosteroid-long-acting beta-agonist inhaler. During the visit, the physician brings up the administration of the annual seasonal influenza vaccine. The patient immediately shakes her head and says, 'I refuse to take that shot. The last time I received it, I was sick with the flu for an entire week. I will never take it again.' Which of the following is the most appropriate initial response by the physician?

During a new patient evaluation, a 42-year-old man establishes care at an internal medicine clinic. He reports no active symptoms and takes no daily medications. Upon reviewing his family history, the physician notes that the patient's father died of colorectal cancer at age 49. The physician recommends scheduling a screening colonoscopy. Hearing this, the patient becomes visibly agitated, crosses his arms, and states, "I am absolutely not doing that. My uncle had a colonoscopy last year, and they tore his intestine. He ended up in the intensive care unit for weeks. Can't we just do one of those take-home stool tests I always see on television?" Which of the following is the most appropriate initial response by the physician?

Match the following common end-of-life clinical scenarios or symptoms with their most appropriate initial palliative intervention.

A 52-year-old man is evaluated in the intensive care unit following a massive aneurysmal subarachnoid hemorrhage. He is deeply comatose, mechanically ventilated, and exhibits no spontaneous movements. The critical care team suspects progression to brain death and plans to formally evaluate him. Assume that during the planned evaluation, the patient develops refractory hypotension immediately upon being disconnected from the ventilator.

Arrange the following steps in the correct chronological sequence for the evaluation and management of this patient:

Match each clinical scenario in advanced illness with the most appropriate next step in targeted symptom management.

A 28-year-old woman, currently at 12 weeks gestation with her first pregnancy, presents to the clinic to discuss her recent laboratory results. Routine prenatal screening confirms a new diagnosis of HIV infection. Her CD4 cell count is 450 cells/mm³ and her HIV viral load is 45,000 copies/mL. She is currently asymptomatic. Upon hearing the diagnosis, the patient becomes distressed and states, "I read online that HIV medications are toxic to the baby's development. I absolutely refuse to take any medications until after my baby is born. Also, I do not want any of my family members to know about this. You must promise not to report my diagnosis to anyone, not even the government." Which of the following is the most appropriate physician response to counsel this patient?

A physician is preparing to disclose a new diagnosis of metastatic lung cancer to a 62-year-old patient in the clinic. According to the widely accepted SPIKES protocol for delivering bad news, arrange the following physician actions in the correct chronological order from first to last.

A 62-year-old woman is evaluated in the clinic to review the results of a recent core needle biopsy of a breast mass. The biopsy results confirm invasive ductal carcinoma. The physician is preparing to deliver this diagnosis to the patient. According to the SPIKES protocol for delivering bad news, arrange the following physician actions in the most appropriate chronological order.

A 75-year-old man with end-stage heart failure is receiving home hospice care. He is fully alert, oriented, and has decision-making capacity. Over the past hour, he has developed severe dyspnea and is visibly distressed. His estranged wife, who is not his designated healthcare proxy, arrives to visit. She becomes panicked by his breathing difficulties and demands that he be taken to the emergency department immediately to be placed on a mechanical ventilator. The patient has a documented out-of-hospital Do Not Resuscitate/Do Not Intubate (DNR/DNI) order and clearly states, "I do not want to go to the hospital; I just want something to help me breathe easier right now." Which of the following is the most appropriate next step in management?

A 50-year-old woman presents to the clinic for a health maintenance examination. Her medical history includes hypertension, hyperlipidemia, and bulimia nervosa. Her daily medications are amlodipine and atorvastatin. During the visit, she mentions that she recently started smoking cigarettes again due to stress at work, bringing her total lifetime smoking history to 5 pack-years. She expresses a strong desire to quit smoking today. Her husband, who is accompanying her, interrupts to say that her anxiety is so severe lately that she is not competent to make her own medical decisions. As part of the patient's comprehensive counseling and health education, which of the following statements by the physician is most appropriate?

A 65-year-old man presents to the ambulatory care office for a follow-up visit one week after being diagnosed with nonvalvular atrial fibrillation. His past medical history is also significant for severe chronic obstructive pulmonary disease. At his previous visit, he was prescribed apixaban for stroke prevention based on a CHA $_2$ DS $_2$-VASc score of 3. Today, the patient states, "I prefer to avoid synthetic medications whenever possible. I have been taking an over-the-counter St. John's wort supplement for the past year to help with occasional sadness. I would rather just take my supplement along with a daily aspirin instead of this new prescription." The patient is alert, fully oriented, and accurately describes the risks of untreated atrial fibrillation, but he expresses a strong personal distrust of pharmaceutical companies. Which of the following is the most appropriate physician response to educate and counsel this patient?

An initial ambulatory care visit is conducted for a 76-year-old male patient who recently relocated to the area to live with his family. He reports feeling well without any acute clinical symptoms. His past medical history is significant for essential hypertension, hyperlipidemia, and mild osteoarthritis. His daily medication regimen consists of lisinopril, atorvastatin, and as-needed acetaminophen. He reports a continuous smoking history of one pack per day starting at age 18 and ending at age 56, maintaining complete abstinence since that time. He denies any lifetime alcohol consumption or recreational drug use. Previous cancer surveillance includes a structurally normal colonoscopy performed 5 years ago at age 71. A detailed review of his state immunization registry and transferred medical records shows the administration of a tetanus-diphtheria-acellular pertussis (Tdap) booster 2 years ago, a seasonal influenza vaccine 2 weeks ago, and a complete two-dose series of the recombinant zoster vaccine at age 66. He has no documented history of receiving a pneumococcal immunization, a respiratory syncytial virus (RSV) immunization, or any serological screening for viral hepatitis. Vital signs are within normal limits, and the physical examination is completely unremarkable.

Based on current evidence-based guidelines, which of the following preventive health interventions should be ordered or administered for this patient today? (Select all that apply.)

A 66-year-old woman with metastatic breast cancer is receiving home hospice care. Over the past five days, her short-acting and long-acting oral morphine doses were significantly increased by the hospice team to manage escalating, diffuse bone pain. Her medical history is notable for hypertension and chronic kidney disease stage 3. Today, the hospice nurse evaluates the patient because her husband reports she has become increasingly restless and confused over the last 24 hours. He notes she was "picking at the air" and claiming there were insects on the wall. Furthermore, her pain appears worse; she grimaces and cries out even when a blanket lightly brushes against her legs. On examination, the patient is agitated and exhibits intermittent, spontaneous jerking movements of her upper and lower extremities. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 110/70 mmHg, heart rate of 95/min, and respiratory rate of 16/min. Which of the following is the most appropriate next step in management?

An oncology team consults palliative care for a patient with advanced pancreatic adenocarcinoma who is experiencing uncontrolled nociceptive pain and severe medication-induced nausea with the current oral oxycodone regimen. The decision is made to rotate the patient to a continuous subcutaneous hydromorphone infusion. To ensure patient safety and avoid accidental opioid toxicity during this transition, arrange the standard steps of opioid rotation in the correct chronological sequence.