Patient Management

A 39-year-old woman is evaluated in the emergency department for severe, sudden-onset periumbilical and epigastric pain radiating to her back, which began 4 hours ago. The pain is continuous and associated with severe nausea and nonbilious emesis. Her medical history is significant for morbid obesity, for which she underwent a laparoscopic Roux-en-Y gastric bypass 3 years ago, resulting in a 55-kg (121-lb) weight loss. Her temperature is 37.8°C (100.0°F), blood pressure is 112/72 mmHg, heart rate is 118/min, and respiratory rate is 20/min. Physical examination reveals a non-distended abdomen with severe tenderness out of proportion to palpation, but without marked rebound tenderness or guarding. Laboratory studies show a leukocyte count of 11,500/mm³ and normal serum lipase, bilirubin, and alkaline phosphatase levels. A CT scan of the abdomen and pelvis with intravenous contrast reveals mild mesenteric edema and a cluster of small bowel loops in the left upper quadrant, but no definitive transition point, free air, or target sign is noted by the radiologist. Over the next hour, her pain becomes entirely refractory to intravenous opioids, and her heart rate increases to 134/min. Which of the following is the most appropriate next step in the management of this patient?

A 78-year-old man with end-stage chronic obstructive pulmonary disease (COPD) is evaluated in the outpatient clinic. He requires continuous supplemental oxygen and has had four hospitalizations in the past year for severe acute exacerbations. He is now completely bedbound and states, "I am tired of going to the hospital and being poked with needles. I just want to stay at home and be comfortable for whatever time I have left." His physician estimates his life expectancy to be less than 6 months. The patient is alert, fully oriented, and clearly articulates an understanding of his prognosis and the medical consequences of his decision. Which of the following is the most appropriate next step in management?

A 68-year-old man is admitted to the inpatient palliative care unit due to progressive, severe dyspnea. He has stage IV non-small cell lung cancer with extensive pleural involvement and lymphangitic carcinomatosis. He is currently awake but visibly distressed, breathing at 32 breaths per minute. His oxygen saturation is 89% on room air. The patient has a 'Do Not Resuscitate / Do Not Intubate' (DNR/DNI) order in place, and his stated primary goal of care is maximum comfort.

Arrange the following interventions in the appropriate stepwise order of escalation for the management of this patient's terminal dyspnea, from the initial step to the final step for refractory symptoms.

A physician is preparing to discuss recent imaging findings with a 59-year-old man and his spouse. The patient underwent a computed tomography scan of the chest due to chronic cough and weight loss, which revealed a large spiculated pulmonary mass with mediastinal lymphadenopathy, highly suspicious for advanced malignancy. The physician plans to deliver this information using the SPIKES protocol. Arrange the following physician statements in the correct chronological sequence to appropriately execute this framework.

A male patient, aged $62$ years, returns to the primary care clinic for a follow-up evaluation. He has a history of type $2$ diabetes mellitus, essential hypertension, and hyperlipidemia. Two weeks ago, his blood pressure was $154/92$ mmHg. At that time, laboratory studies demonstrated a serum creatinine of $1.1$ mg/dL, a serum potassium of $4.2$ mEq/L, and a urine albumin-to-creatinine ratio of $210$ mg/g. To address his hypertension and microalbuminuria, ramipril was initiated. Today, the patient reports feeling well with no lightheadedness, shortness of breath, or peripheral edema. His blood pressure is now $132/82$ mmHg, and his heart rate is $74$/min. Repeat laboratory studies obtained this morning show a serum sodium of $139$ mEq/L, a serum potassium of $4.8$ mEq/L, a blood urea nitrogen of $16$ mg/dL, and a serum creatinine of $1.4$ mg/dL. Which of the following is the most appropriate next step in management?

A 68-year-old male with a history of type 2 diabetes mellitus is admitted to the intensive care unit due to severe community-acquired pneumonia and worsening hypotension. His weight is 80 kg. Upon arrival, his blood pressure is 75/40 mm Hg, heart rate is 128/min, and respiratory rate is 28/min. Initial laboratory results demonstrate a serum lactate of 5.2 mmol/L. Appropriate empiric broad-spectrum antibiotics have already been administered. Arrange the following pharmacologic interventions in the correct sequential order of escalation for managing this patient's hemodynamics, assuming he remains persistently hypotensive after each preceding step is fully implemented.

A 65-year-old man presents to the clinic with severe pain, swelling, and redness in his right knee that began 24 hours ago. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 30%, chronic kidney disease stage 4 with a baseline estimated glomerular filtration rate of 22 mL/min/1.73 m², and a prior episode of upper gastrointestinal bleeding secondary to a peptic ulcer. Vital signs show a temperature of 37.4°C (99.3°F), blood pressure of 110/70 mmHg, and heart rate of 82/min. Physical examination reveals a warm, erythematous, and markedly tender right knee with a moderate effusion. Arthrocentesis is performed, and synovial fluid analysis reveals a leukocyte count of 28,000/mm³ and the presence of negatively birefringent, needle-shaped crystals under polarizing microscopy. Gram stain reveals no organisms. Which of the following is the most appropriate initial pharmacologic intervention for this patient's acute symptoms?

A 32-year-old woman with relapsing-remitting multiple sclerosis presents to the clinic to discuss changing her disease-modifying therapy. She has experienced two clinical relapses in the past year while receiving glatiramer acetate. The physician plans to prescribe fingolimod. The patient has no other significant past medical history. She was born outside the United States, has no records of her childhood immunizations, and does not recall having chickenpox. Her physical examination is notable for mild residual weakness in her left lower extremity.

Which of the following baseline evaluations are required prior to initiating this medication? (Select all that apply)

Determine the optimal post-discharge transition for the following individuals who no longer require acute inpatient hospitalization. Select the corresponding facility or service that best aligns with each individual's functional capacity and ongoing medical requirements.

A 68-year-old man is being prepared for discharge after a 6-day hospitalization for a severe exacerbation of chronic obstructive pulmonary disease (COPD). His acute symptoms have resolved, but he exhibits persistent hypoxemia. The multidisciplinary care team determines he will require new long-term home oxygen therapy (LTOT). Arrange the following steps in the most appropriate chronological order to safely execute this care setting transition.

A 72-year-old man is admitted to the inpatient medical ward for severe, poorly controlled lower back and pelvic pain secondary to metastatic prostate cancer. He reports that the pain has progressively worsened over the past two weeks and is now 9/10 in intensity. His current pain regimen consists of oral acetaminophen and oral ibuprofen, which currently provide minimal relief. His medical history is significant for hypertension, major depressive disorder, and chronic kidney disease stage 4 (baseline estimated glomerular filtration rate is 22 mL/min/1.73 m²). Current daily medications include amlodipine, sertraline, acetaminophen, and ibuprofen. Vital signs are temperature 37.1°C (98.8°F), blood pressure 152/88 mm Hg, pulse 98/min, and respirations 18/min. Physical examination reveals exquisite tenderness to palpation over the lumbar spine and posterior pelvis. The patient is awake, alert, and expresses a strong desire for immediate pain relief. The attending physician plans to discontinue the ibuprofen and initiate a strong opioid. Which of the following is the most appropriate pharmacologic intervention for this patient's pain?

A $45$-year-old man comes to the clinic for a routine follow-up. Four weeks ago, he was diagnosed with active pulmonary tuberculosis and started on a regimen of isoniazid, rifampin, pyrazinamide, and ethambutol. He reports excellent adherence to the medications and says his chronic cough and night sweats have completely resolved. He currently feels well and has no nausea, vomiting, abdominal pain, fatigue, or dark urine. Vital signs are within normal limits. Physical examination reveals no scleral icterus, right upper quadrant tenderness, or hepatomegaly.

Laboratory studies show:

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

Emergency medical services bring a $72$-year-old woman to the emergency department after her daughter found her profoundly weak and confused at home. According to the daughter, the patient has had severe nausea, vomiting, and non-bloody diarrhea for the past $3$ days.

The patient's medical history includes type 2 diabetes mellitus, hypertension, and osteoarthritis. Her home medications include metformin, empagliflozin, lisinopril, and naproxen as needed.

Physical examination reveals dry oral mucous membranes, poor skin turgor, and delayed capillary refill. She is lethargic but arousable and oriented to person.

*(Baseline creatinine from one month ago was $0.9\text{ mg/dL}$)*

Which of the following pharmacologic interventions are most appropriate in the initial management of this patient? (Select all that apply)

A 72-year-old man is evaluated prior to discharge from the hospital following an admission for highly symptomatic atrial fibrillation. His past medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus. During hospitalization, his heart rate remained inadequately controlled despite maximum tolerated doses of metoprolol. The cardiology service initiated oral amiodarone for rhythm control, and the patient successfully converted to normal sinus rhythm. He is transitioning to outpatient care on his newly adjusted medication regimen, which includes amiodarone, metoprolol, apixaban, atorvastatin, and metformin. Which of the following tests are indicated for the routine baseline and ongoing monitoring of his new antiarrhythmic therapy? (Select all that apply)

A 52-year-old woman is evaluated in the hospital for worsening erythema, warmth, and swelling of her right lower extremity. She was admitted 3 days ago for severe cellulitis and was started on empiric intravenous vancomycin and piperacillin-tazobactam. Her past medical history is significant for major depressive disorder and type 2 diabetes mellitus. Her home medications, which were continued on admission, include citalopram, metformin, and insulin glargine.

Today, her temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $122/78\text{ mmHg}$, heart rate is $98/\text{min}$, and respiratory rate is $16/\text{min}$. The erythema on her right leg has expanded proximally despite 72 hours of antimicrobial therapy. Blood cultures drawn on admission remain negative, but a tissue culture obtained from the leading edge of the cellulitis on admission grows *Enterococcus faecium*. Antimicrobial susceptibility testing reveals resistance to ampicillin and vancomycin. Renal function is within normal limits.

Which of the following is the most appropriate pharmacologic intervention for this patient?

A $54$-year-old woman is evaluated in the oncology clinic prior to initiating adjuvant therapy for early-stage, HER2-positive breast cancer. Her planned regimen includes weekly paclitaxel concurrently with trastuzumab. She has a history of well-controlled essential hypertension. The physician discusses the potential adverse effects of her targeted therapy, specifically emphasizing the risk of cardiotoxicity, and outlines a comprehensive monitoring protocol. Arrange the following steps regarding the cardiac monitoring and treatment evaluation for this patient in the correct chronological and clinical sequence.

A 68-year-old male is evaluated in the outpatient clinic for new-onset muscle pain and weakness. He is currently on day 14 of a planned 28-day course of intravenous daptomycin for right-sided infective endocarditis caused by methicillin-resistant *Staphylococcus aureus* (MRSA). His medical history is significant for coronary artery disease and hyperlipidemia, for which he takes aspirin, metoprolol, and rosuvastatin. The patient states that the muscle aches began three days ago, primarily affecting his bilateral thighs and shoulders, making it difficult to stand up from a seated position. His temperature is 37.1°C (98.8°F), blood pressure is 132/84 mmHg, and pulse is 76/min. Physical examination reveals symmetrical muscle tenderness to palpation in the proximal upper and lower extremities. Sensation and deep tendon reflexes are intact. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man presents to the clinic with a 4-day history of increased cough, increased sputum volume that has become markedly purulent, and worsening dyspnea. He has a past medical history of severe chronic obstructive pulmonary disease (COPD), hyperlipidemia, and paroxysmal atrial fibrillation. His current daily medications include a tiotropium inhaler, a formoterol inhaler, simvastatin, and sotalol. Vital signs show a temperature of $37.5^\circ\text{C}$ ($99.5^\circ\text{F}$), blood pressure of $135/85\text{ mmHg}$, heart rate of $76/\text{min}$, and respiratory rate of $22/\text{min}$. Oxygen saturation is $92\%$ on room air. Pulmonary auscultation reveals a prolonged expiratory phase with diffuse bilateral wheezing. Laboratory studies show a leukocyte count of $8,500/\mu L$ and a serum creatinine of $1.0\text{ mg/dL}$. An electrocardiogram obtained in the clinic demonstrates normal sinus rhythm with a corrected QT (QTc) interval of $535\text{ ms}$. The physician plans to prescribe a 5-day course of oral prednisone and optimize the patient's bronchodilator therapy. Which of the following is the most appropriate antimicrobial approach for this patient?

An infectious diseases consultation is requested for a 34-year-old male inpatient who has been experiencing progressive dyspnea, dry cough, and subjective fevers over the past three weeks. His past medical history is notable for an HIV diagnosis five years prior; however, he abandoned antiretroviral therapy two years ago. Vital signs reveal a temperature of $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure of 112/70 mmHg, heart rate of 110/min, and respiratory rate of 24/min. Pulse oximetry demonstrates an oxygen saturation of $88\%$ while breathing ambient air, and a subsequent arterial blood gas analysis confirms a $\text{PaO}_2$ of 65 mmHg. Chest radiography displays bilateral, fine interstitial infiltrates. Microscopic examination of induced sputum using direct fluorescent antibody testing definitively identifies *Pneumocystis jirovecii*.

Which of the following pharmacologic interventions should be ordered immediately for this patient? (Select all that apply)

A 63-year-old female presents to the clinic for a routine annual wellness examination. She feels well and has no acute complaints. Her medical history is significant for type 2 diabetes mellitus and primary hypertension. Her current medications include metformin and lisinopril. Vital signs are within normal limits, and her body mass index is 27 kg/m². She has never smoked and drinks one glass of wine on weekends.

Review of her preventive care history reveals the following:
- Screening mammography: Performed 11 months ago, BI-RADS 1 (negative).
- Cervical cancer screening: Pap smear with HPV co-testing performed at age 60, negative for intraepithelial lesions and high-risk HPV.
- Colorectal cancer screening: Colonoscopy performed at age 53, revealing no polyps or abnormalities.
- Vaccinations: Received 2 doses of the recombinant zoster vaccine at age 50. Received the 20-valent pneumococcal conjugate vaccine (PCV20) at age 61. Received a Tdap booster 6 years ago. Received an annual influenza vaccine last month.

The patient asks if she is due for any other screening tests or preventive medications today. Which of the following is the most appropriate next step in this patient's preventive care?