Patient Management

A 61-year-old man comes to the clinic for a 2-week follow-up visit after being diagnosed with essential hypertension and type 2 diabetes mellitus with microalbuminuria. At his last visit, he was started on ramipril. The patient reports feeling well and has no dizziness, fatigue, or peripheral edema. His blood pressure today is 132/82 mm Hg, a significant improvement from 158/94 mm Hg at his previous visit. His pulse is 72/min. Physical examination is unremarkable.

The patient's laboratory results are as follows:

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

A 58-year-old man comes to the clinic for a follow-up visit 2 weeks after being diagnosed with primary hypertension. At his last visit, lifestyle modifications were recommended, and he was started on lisinopril. He reports feeling well and has no new symptoms. His blood pressure today is 132/84 mm Hg, and his heart rate is 72/min. Physical examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old female presents to the clinic for a routine wellness and preconception counseling visit. She and her partner plan to start trying to conceive in the next 3 months. Her medical history is significant for severe Crohn's disease, which has been in clinical and endoscopic remission for the past two years on maintenance therapy with infliximab. She has no other medical conditions and takes a daily prenatal vitamin. She recalls never having chickenpox as a child, and a recent occupational health laboratory screening showed negative varicella-zoster virus (VZV) IgG antibodies. Her only previous cervical cancer screening was a normal Pap smear (cervical cytology) at age 23. She received a Tdap booster 2 years ago and an inactivated influenza vaccine 1 month ago. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in her preventive care?

A 65-year-old man with metastatic prostate cancer presents to the palliative care clinic with severe, constant lower back and pelvic pain. He is currently opioid-naive, and his pain is poorly controlled despite maximum scheduled doses of nonsteroidal anti-inflammatory drugs (NSAIDs). An evaluation confirms the pain is primarily nociceptive secondary to osseous metastases. The physician decides to initiate strong opioid therapy.

Arrange the following steps in the most appropriate chronological sequence for safely establishing and optimizing a long-term opioid regimen for this opioid-naive patient, from initial prescribing to long-term maintenance.

A 48-year-old man presents to the emergency department with a 1-day history of right-sided pleuritic chest pain. He has no significant past medical history and takes no medications. He does not smoke or use illicit substances. His temperature is 37.0°C (98.6°F), blood pressure is 128/82 mm Hg, pulse is 88/min, and respiratory rate is 16/min. Pulse oximetry shows 98% on room air. Physical examination reveals clear lungs, normal heart sounds, and no lower extremity edema or calf tenderness. Laboratory studies are notable for a high-sensitivity troponin T of < 0.01 ng/mL and an N-terminal pro-B-type natriuretic peptide (NT-proBNP) of 60 pg/mL (normal: < 125 pg/mL). Renal function is normal. A computed tomography pulmonary angiogram demonstrates a segmental pulmonary embolism in the right lower lobe. The right-to-left ventricular diameter ratio is 0.8. The patient is accompanied by his wife, and they live in an apartment 10 minutes from the hospital. He demonstrates clear understanding of his diagnosis. Which of the following is the most appropriate disposition and initial management plan for this patient?

A 68-year-old man is hospitalized with a severe exacerbation of chronic obstructive pulmonary disease. Despite maximal medical therapy and noninvasive positive pressure ventilation, his respiratory status continues to deteriorate. Arterial blood gas analysis reveals a PaCO2 of 88 mm Hg and a PaO2 of 52 mm Hg. The patient is now obtunded, opening his eyes only to painful stimuli, and is unable to communicate his wishes. The intensive care team determines that endotracheal intubation and mechanical ventilation are indicated to preserve his life.

The patient's electronic medical record contains a valid advance directive completed one year ago. The document explicitly names his eldest son as his healthcare proxy and states a firm desire to avoid mechanical ventilation under any circumstances. The patient's wife, who has been married to him for 40 years and is present at the bedside, tearfully demands that the team intubate him immediately, stating, "I am his wife, and I cannot lose him today. Do everything you can." The son, who is contacted by telephone, states, "My father was very clear with me. He would never want to live on a machine. Please keep him comfortable."

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

A 62-year-old woman presents to the clinic for routine follow-up of her anticoagulation therapy. She has a history of a mechanical mitral valve replacement and has been maintained on warfarin. Her international normalized ratio (INR) has historically been stable between 2.5 and 3.5. Today, her INR is 1.4. When asked about any changes to her diet or medications, the patient reluctantly admits that she started taking a St. John's wort supplement three weeks ago to help with mild depressive symptoms following the death of her pet. She states defensively, "Please don't tell me to stop taking it. It's natural, it makes me feel so much better, and I hate being reliant on all these synthetic chemicals from the pharmacy."

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

A 62-year-old man is evaluated in the surgical intensive care unit. He was admitted $6$ days ago following an emergency exploratory laparotomy and small bowel resection for mesenteric ischemia. Postoperatively, he developed a deep vein thrombosis in his right lower extremity and was started on a continuous intravenous unfractionated heparin infusion.

The patient's target activated partial thromboplastin time (aPTT) is $60-80$ seconds. His daily laboratory trends are shown below:

Today, the patient reports mild worsening of his right leg pain. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $135/82$ mmHg, heart rate $92$/min, and respirations $16$/min. Physical examination shows persistent right calf swelling and a new area of erythema and induration at a recent peripheral intravenous catheter site.

Based on the clinical and laboratory monitoring parameters provided, which of the following is the most appropriate next step in management?

Evaluate the clinical presentations below. Match each patient scenario to the most appropriate disposition and care setting transition based on validated risk stratification criteria.

A 66-year-old biological female presents to the clinic for a routine health maintenance visit. Her past medical history is significant for well-controlled type 2 diabetes mellitus and primary hypertension. Her current medications include metformin and lisinopril. She has never smoked, drinks wine occasionally, and denies illicit drug use. She reports feeling well and has no current complaints.

A review of her medical records reveals the following:
- A screening colonoscopy performed at age 62 was unremarkable.
- A screening mammogram performed 6 months ago was normal.
- Dual-energy x-ray absorptiometry performed at age 65 showed osteopenia with a T-score of $-1.4$.
- She has a history of three consecutive normal Papanicolaou (Pap) tests, the most recent being at age 64.
- She received a tetanus, diphtheria, and acellular pertussis (Tdap) booster at age 60 and completed the recombinant zoster vaccine series at age 55.
- She has never received a pneumococcal vaccination.
- There is no record of prior hepatitis screening in her medical chart.

Based on current United States Preventive Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP) guidelines, which of the following preventive interventions are indicated for this patient at today's visit? (Select all that apply)

A $24$-year-old man with a history of type 1 diabetes mellitus is brought to the emergency department with abdominal pain, nausea, and vomiting. Laboratory studies show a serum glucose of $580 \text{ mg/dL}$, bicarbonate of $12 \text{ mEq/L}$, and an anion gap of $22$. He is diagnosed with diabetic ketoacidosis. Assuming his initial serum potassium is $4.5 \text{ mEq/L}$, arrange the following management steps in the correct sequential order according to standard treatment protocols.

Match each patient presentation to the single most appropriate next step in preventive care and screening according to current guidelines.

An initial primary care evaluation is conducted for a 55-year-old biological female who recently relocated to the area. Her medical background is notable for type 1 diabetes mellitus complicated by end-stage renal disease, requiring hemodialysis three times weekly. She actively smokes and has a 30 pack-year smoking history. Surgically, she underwent a total abdominal hysterectomy ten years ago for symptomatic uterine fibroids. Her preventive care records indicate her last screening mammogram occurred three years ago, and her most recent screening colonoscopy, performed five years ago, was entirely normal. She has not received any vaccinations during the past decade. The patient is compliant with her medications and dialysis regimen. Vital signs and physical examination reveal no acute abnormalities. Which of the following preventive interventions are indicated for this patient today? (Select all that apply)

A 69-year-old man comes to the clinic for a routine health maintenance examination. He has no acute complaints. His medical history includes primary hypertension and gastroesophageal reflux disease, which are well controlled with amlodipine and pantoprazole. He smoked 1 pack of cigarettes daily from age 18 to 50 (32 pack-years) but quit 19 years ago. He drinks alcohol occasionally and does not use illicit drugs. His last colonoscopy was performed at age 63 and showed no polyps or other abnormalities. A hepatitis C virus antibody test was negative three years ago. He received the 2-dose recombinant zoster vaccine series at age 65 and a 20-valent pneumococcal conjugate vaccine (PCV20) at age 66. He received a Tdap booster 4 years ago. Vital signs today are blood pressure 126/78 mm Hg, pulse 70/min, and respirations 14/min. Physical examination is unremarkable. Which of the following is the most appropriate next step in preventive care for this patient?

A 61-year-old woman is evaluated in the hospital for altered mental status. She was admitted 3 days ago for management of acute kidney injury secondary to ureteral obstruction. Her past medical history is significant for advanced cervical cancer, and her severe pelvic pain has been well controlled at home with high-dose extended-release oral morphine.

Today, the patient's partner reports that she has become progressively confused and agitated overnight. On examination, the patient is somnolent but groans and withdraws to light touch, demonstrating severe tactile allodynia. She frequently exhibits involuntary, rapid muscle jerks in all four extremities. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 110/70 mmHg, heart rate of 98/min, and respiratory rate of 18/min. Oxygen saturation is 97% on room air. Laboratory studies show a serum creatinine of 3.8 mg/dL (baseline 1.1 mg/dL). Which of the following is the most appropriate next step in the management of this patient's symptoms?

Seeking guidance on cancer risk reduction, a 38-year-old biological male visits his primary care physician for a wellness check. He feels well and reports no rectal bleeding, weight loss, or change in stool caliber. His only medication is a daily multivitamin. Family history is significant for his mother being diagnosed with adenocarcinoma of the colon when she was 45 years of age. Consistent with high-risk surveillance guidelines, the patient underwent an initial screening colonoscopy three years ago (at age 35); the procedure was entirely normal with no polyps identified. He does not use tobacco or illicit substances. His vital signs and physical examination are within normal limits. Which of the following is the most appropriate management regarding colorectal cancer screening for this patient?

A 34-year-old male is evaluated via a telemedicine consultation for follow-up of newly diagnosed type 2 diabetes mellitus. His medical history is significant for ischemic cardiomyopathy resulting in NYHA class III heart failure. Two weeks ago, his hemoglobin A1c was 8.2%, and he was prescribed metformin along with counseling on dietary modifications. Today, the patient states, 'I have not picked up the prescription. I watched a documentary claiming that diabetes medications are highly toxic to the body. Instead, I have decided to cure my condition with a strict 30-day fruit juice cleanse.' Which of the following is the most appropriate initial response by the physician?

A palliative care attending physician at a tertiary medical center is reviewing several patient charts to formulate targeted recommendations for symptom control and care transitions. Match each of the following clinical scenarios with the most appropriate next step in palliative or end-of-life management.

A 54-year-old woman is evaluated for discharge planning on hospital day 14. She was initially admitted to the intensive care unit for severe acute pancreatitis complicated by acute respiratory distress syndrome, which required mechanical ventilation for 7 days. She was successfully extubated 4 days ago and transferred to the general medical floor. The patient is awake, alert, and oriented. Vital signs are within normal limits. Oxygen saturation is 96% on room air. She is tolerating an oral diet, and her pain is well controlled with oral analgesics. All invasive lines and drains have been removed.

Physical and occupational therapy evaluation reveals profound ICU-acquired weakness. The patient requires maximum assistance for bed-to-chair transfers and is unable to bear weight independently. During her evaluation, she becomes easily fatigued and can actively participate in therapy for only 30 to 45 minutes daily before requiring extended rest. Prior to her hospitalization, she lived alone in a single-family home. Her immediate family lives nearby but they work full-time and cannot provide around-the-clock care.

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

A patient who recently turned 65 years old presents to establish care at a new primary care practice. His past medical history is unremarkable, and he takes no medications. He mentions that he has smoked one pack of cigarettes per day since he was 25 years old and continues to smoke. He feels well and denies any respiratory symptoms, changes in bowel habits, or abdominal pain. He has not seen a physician in over 15 years and has never undergone any formal health maintenance screenings. Based on current guidelines, which of the following preventive interventions are strongly indicated for this patient? (Select all that apply)