Patient Management

A 58-year-old man with newly diagnosed type 2 diabetes mellitus and hypertension presents for a follow-up visit. He was prescribed metformin and lisinopril two weeks ago. Today, he reports that he has not started taking either medication. He states, 'I do not want to be dependent on pills for the rest of my life. My cousin reversed his diabetes entirely by going on a strict juice cleanse and taking herbal detox supplements, and I want to try that first.' His blood pressure today is 152/94 mmHg and his hemoglobin A1c is 8.4%. Which of the following is the most appropriate initial physician response?

A 42-year-old woman is evaluated in the outpatient clinic to review the results of a recent breast biopsy. The patient had presented with a palpable, painless lump in her right breast, and subsequent mammography showed a highly suspicious mass with microcalcifications. The core needle biopsy results have just returned, confirming invasive ductal carcinoma. The physician is preparing to disclose these findings to the patient, who is waiting in the consultation room.

Arrange the following physician actions and statements in the most appropriate chronological sequence for delivering this news, in accordance with the standard protocol.

A 65-year-old man is brought to the intensive care unit after suffering a massive intracerebral hemorrhage. He is intubated, deeply comatose, and lacks decision-making capacity. The social worker confirms that no advance directive or legally appointed healthcare proxy is available in his medical records or state registry. Several relatives arrive at the hospital and express conflicting wishes regarding his goals of care. The attending physician must identify the primary surrogate decision-maker to proceed with care planning.

Arrange the following relatives in the standard legal order of priority for surrogate decision-making, from highest priority (first) to lowest priority (last).

A 42-year-old woman presents to the clinic for a routine check-up. She is highly anxious because her close friend was recently diagnosed with advanced cervical cancer. The patient strongly requests a Papanicolaou (Pap) test and human papillomavirus (HPV) co-testing today. Her medical record shows she had a normal Pap test and a negative HPV co-test two years ago. She has no history of abnormal cervical cancer screening results, no new sexual partners, and is immunocompetent. Which of the following is the most appropriate physician response to address this patient's request?

An internal medicine physician is reviewing the charts of four patients scheduled for ambulatory clinic visits today. Match each patient's clinical profile with the most appropriate next step in preventive care based on current United States Preventive Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP) guidelines.

A physician is using motivational interviewing techniques to counsel a patient on smoking cessation. Match each motivational interviewing core skill to the corresponding physician statement.

A 35-year-old woman, gravida 2, para 1, at 24 weeks gestation presents to the clinic for a routine prenatal visit. She has a history of a mechanical aortic valve replacement performed five years ago. Since confirming her pregnancy, her anticoagulation regimen was transitioned to therapeutic-dose enoxaparin. During the visit, the patient appears highly anxious. She states, 'I was reading a natural parenting blog last night, and it said that all injectable medications given during pregnancy cause severe birth defects. I am stopping these injections immediately. From now on, I will only take a daily baby aspirin because it is natural and safe. I know what is best for my baby.'

Which of the following is the most appropriate initial response by the physician?

An 82-year-old woman is admitted to the intensive care unit following a massive intracranial hemorrhage. She is currently intubated, comatose, and has a very poor prognosis for meaningful neurological recovery. Her son, who is her designated healthcare proxy, has just arrived at the hospital. The attending physician plans to meet with him to discuss the patient's prognosis and establish goals of care.

Based on established clinical communication protocols for delivering bad news and shared decision-making, arrange the following physician actions in the most appropriate chronological sequence.

A 71-year-old male patient with advanced prostate cancer is currently managed on home hospice. Over the past 48 hours, his family reports that he has become highly agitated, disoriented, and is experiencing visual hallucinations of strangers in his bedroom. He is frequently picking at his bedsheets and attempting to stand up unassisted. His current pain regimen includes a transdermal fentanyl patch, which has provided excellent relief; he has not required any breakthrough medication in the past week and denies pain when calmly asked. A physical examination by the visiting hospice nurse reveals stable vital signs, a soft abdomen with regular bowel movements, and a bladder scan showing no retained urine. Which of the following is the most appropriate next step in the management of this patient's current symptoms?

Match each advanced end-of-life clinical scenario to the most appropriate next step in targeted pharmacological management.

During a routine wellness examination, a physician evaluates a 65-year-old male patient. His medical history is notable only for mild osteoarthritis, managed with occasional ibuprofen. The patient reports feeling excellent, exercises regularly, and denies any current symptoms. Upon reviewing the electronic health record, the physician notices an absence of prior colorectal cancer screening. When the physician suggests scheduling a colonoscopy, the patient shakes his head and says, 'I feel perfectly fine. Since I don't have any abdominal pain or blood in my stool, undergoing tests seems completely unnecessary.' Which of the following is the most appropriate initial counseling response by the physician?

A 54-year-old male presents to the clinic to establish care. He recently moved to the area and has not seen a physician in several years. His past medical history is significant for left-sided ulcerative colitis, which was diagnosed 15 years ago. His gastrointestinal symptoms have been well-controlled on daily oral mesalamine. The patient has a 30-pack-year smoking history and continues to smoke one pack of cigarettes daily. He drinks alcohol socially and does not use illicit drugs. Vital signs are within normal limits. Physical examination reveals a soft, non-tender abdomen with no organomegaly. Review of his medical records indicates that his last colonoscopy was performed 6 years ago; it showed quiescent colitis with no evidence of dysplasia. He has never been screened for lung cancer. He received a tetanus, diphtheria, and acellular pertussis (Tdap) booster 2 years ago and an influenza vaccine last month. Which of the following is the most appropriate next step in this patient's preventive care?

An 84-year-old woman is admitted to the medical ward for treatment of her third episode of aspiration pneumonia in the past four months. Her past medical history is significant for advanced Alzheimer disease, hypertension, and osteoarthritis. She is completely bedbound, nonverbal, and dependent on caregivers for all activities of daily living. A speech-language pathology evaluation demonstrates profound oropharyngeal dysphagia with silent aspiration on all consistencies. The patient has no formal living will, but her daughter is the legally designated healthcare proxy. The daughter expresses deep distress over her mother's recent weight loss and asks the physician to arrange for a percutaneous endoscopic gastrostomy (PEG) tube placement, stating, "I cannot just watch her starve to death." Which of the following is the most appropriate next step in management?

Match each clinical scenario to the most appropriate level of palliative or hospice care.

A primary care physician is evaluating multiple patients during a busy clinic day. Each patient presents with a distinct barrier to adhering to their recommended management plan. Match each patient's clinical scenario and statement to the most appropriate initial physician counseling strategy.

A 68-year-old woman is admitted to the oncology ward for management of intractable bone pain secondary to metastatic breast cancer. Her pain has been reasonably controlled for the past month on high-dose extended-release oral morphine, with immediate-release morphine used as needed for breakthrough pain. Over the past 48 hours, her family reports that she has become increasingly confused, agitated, and restless. On physical examination, the patient is disoriented and exhibits spontaneous, irregular jerking movements of her extremities. When the physician gently palpates her arm to check her pulse, she grimaces and cries out in severe pain. Laboratory studies reveal a blood urea nitrogen of 42 mg/dL and a serum creatinine of 2.4 mg/dL (baseline 0.9 mg/dL one week ago). Which of the following is the most appropriate next step in management?

A primary care physician is counseling several patients with type 2 diabetes regarding insulin therapy. Each patient presents with a distinct barrier to initiating or maintaining treatment. Match each patient statement with the most appropriate, targeted physician counseling response.

A 32-year-old teacher presents to an urgent care clinic complaining of a 3-day history of nasal congestion, sore throat, and a dry cough. She appears anxious and states, 'I have a critical parent-teacher conference in two days. Whenever this happens, my old doctor gave me a Z-Pak, and it fixed me right up. I really need that prescription today.' Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, and pulse is 78/min. Physical examination reveals clear rhinorrhea and mild pharyngeal erythema with no tonsillar exudates. Auscultation of the lungs is clear bilaterally. Which of the following is the most appropriate initial communication strategy by the physician?

A 66-year-old woman comes to the office for a routine health maintenance evaluation. She has a past medical history of estrogen receptor-positive left breast cancer treated with a lumpectomy and radiation therapy at age 52. She subsequently completed a 5-year course of letrozole and has remained in remission. Her social history is notable for smoking one pack of cigarettes daily for 30 years, but she successfully quit 16 years ago.

Her most recent preventive care includes:
- A screening colonoscopy at age 56, which revealed no polyps.
- Mammography of both breasts 12 months ago, which showed post-surgical changes on the left and no evidence of malignancy (BI-RADS 2).
- Cervical cytology with high-risk human papillomavirus (hrHPV) co-testing at age 62, which was negative for both. She also had a negative co-test at age 57, and no history of high-grade precancerous cervical lesions.

She has no new physical complaints. Her body mass index is 25 kg/m².

Which of the following is the most appropriate set of cancer screening recommendations for this patient today?

Match the following end-of-life clinical scenarios or symptoms with their most appropriate first-line pharmacological intervention.