Patient Management

A 28-year-old man recently diagnosed with HIV infection returns to the clinic to discuss his laboratory results. His CD4 cell count is 650/mm³ and his HIV viral load is 45,000 copies/mL. He is currently asymptomatic and has no other medical conditions. During the visit, the physician recommends initiating daily antiretroviral therapy (ART). The patient crosses his arms, shakes his head, and says, "I have been reading a lot online, and I decided I am not going to take those toxic chemicals. I feel perfectly fine right now. I will only consider taking them if my immune system actually starts failing and I get sick." Which of the following is the most appropriate initial response by the physician?

Review the following patient presentations from today's primary care clinic. For each patient, select the single most appropriate next step in preventive care based on current United States Preventive Services Task Force (USPSTF) guidelines.

A 42-year-old woman is evaluated in the clinic prior to a change in her medication regimen. She has a 4-year history of seropositive rheumatoid arthritis. For the past year, she has been managed with sulfasalazine and hydroxychloroquine, but she reports persistent morning stiffness lasting over two hours and increasing pain in her wrists and hands. Examination shows synovitis with effusions in the bilateral wrists, metacarpophalangeal joints, and proximal interphalangeal joints. Radiographs of the hands reveal new periarticular erosions. The physician decides to discontinue sulfasalazine and initiate therapy with methotrexate and infliximab. The patient has no history of cardiovascular or liver disease, and her physical examination is otherwise unremarkable. Which of the following baseline screening tests are strictly required before initiating this new pharmacologic regimen? (Select all that apply)

A hospital ethics committee is reviewing several complex cases regarding end-of-life decision-making and patient autonomy. Pair each patient vignette with the foundational ethical principle or legal standard that best justifies the clinical action taken.

Emergency medical services bring a 79-year-old male to the emergency department due to severe shortness of breath. The patient has a known history of end-stage heart failure with reduced ejection fraction and stage 5 chronic kidney disease (baseline creatinine 3.9 mg/dL). Upon arrival, he is lethargic, obtunded, and incapable of meaningfully participating in his medical care. He exhibits profound respiratory distress with prominent use of accessory muscles.

His daughter accompanies him and provides the physician with legal documentation establishing her as the designated healthcare proxy, alongside a valid advance directive. The directive explicitly refuses endotracheal intubation and cardiopulmonary resuscitation, requesting only symptom-directed comfort care. Shortly thereafter, the patient's estranged son arrives. He becomes visibly upset, demanding that the patient be immediately intubated and transferred to the intensive care unit, threatening litigation if aggressive life-sustaining measures are withheld.

The attending physician concludes that intubation contradicts both the documented advance directive and the proxy's instructions. Meanwhile, the daughter urgently asks for medications to relieve her father's severe breathing difficulty.

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

During an annual wellness evaluation, a physician is discussing preventive health measures with a healthy individual who recently turned 52. The individual has a 35-pack-year smoking history and currently smokes one pack of cigarettes daily. When the physician introduces the topic of low-dose computed tomography for lung cancer screening, the individual abruptly crosses their arms and says, "I am not doing any cancer tests. Every time I come here, I get a lecture about my habits. My uncle smoked his whole life and died peacefully at 95." Which of the following is the most appropriate initial communication strategy for the physician to employ?

A 54-year-old biological female presents to the clinic for a routine health maintenance visit. Her medical history is significant for hypertension, hyperlipidemia, and chronic kidney disease stage 3a with a baseline estimated glomerular filtration rate of 52 mL/min/1.73 m². She is a former smoker who smoked 1.5 packs of cigarettes per day from age 37 to age 49 (a total of 12 years) before quitting completely 5 years ago. Current medications include lisinopril and rosuvastatin. Her body mass index is 29 kg/m².

Vaccination history:
- Up to date on seasonal influenza and COVID-19 vaccines.
- Received a Tdap booster 4 years ago after a minor kitchen laceration.
- Received two doses of the recombinant zoster vaccine at age 51.
- She has never received a pneumococcal vaccine.

Screening history:
- Screening colonoscopy at age 48 was completely normal.
- Pap smear with HPV co-testing 3 years ago was negative for intraepithelial lesion or malignancy.
- Hepatitis C virus antibody testing at age 50 was negative.
- Screening mammography 11 months ago was interpreted as BI-RADS 1 (negative).

Which of the following is the most appropriate next step in preventive care and screening for this patient today?

A 42-year-old woman visits the outpatient clinic for a general wellness examination. She feels well and has no specific health concerns. Her medical history is unremarkable, and she takes no daily medications. Her family history is notable for a mother with cervical cancer at age 55, but there is no family history of breast, ovarian, or colon cancer. Menarche occurred at age 13, and she has regular menstrual cycles. Vital signs are within normal limits. Physical examination, including a clinical breast examination, reveals no abnormalities. She has never undergone any breast imaging.

Based on current United States Preventive Services Task Force (USPSTF) guidelines, which of the following is the most appropriate next step in management for this patient?

Match each patient presentation from the primary care clinic with the most appropriate next step in preventive screening according to current United States Preventive Services Task Force (USPSTF) guidelines.

A 70-year-old male presents to the clinic to establish primary care. He has not seen a physician in over a decade. His past medical history is significant for severe chronic obstructive pulmonary disease (COPD) requiring continuous home oxygen therapy (FEV1 32% of predicted), and ischemic cardiomyopathy with a left ventricular ejection fraction of 25% and NYHA Class III symptoms. He reports being housebound due to dyspnea on minimal exertion. He currently feels at his baseline and denies abdominal pain, changes in bowel habits, or rectal bleeding. A complete blood count reveals a hemoglobin of 14.5 g/dL. He has never undergone colorectal cancer screening but asks if he should be tested now because a close friend was recently diagnosed with colon polyps. Which of the following is the most appropriate next step regarding colorectal cancer screening for this patient?

A 54-year-old woman comes to the clinic to discuss her recent laboratory results and health maintenance plan. She has a 10-year history of type 2 diabetes mellitus and chronic kidney disease stage 3a (estimated glomerular filtration rate of 52 mL/min/1.73 m²). Her current medications include metformin, sitagliptin, and lisinopril. Today, her hemoglobin A1c is 9.1%, and her blood pressure is 138/86 mm Hg.

During the visit, the patient expresses frustration: "I know my blood sugar is still high, but I am absolutely terrified of starting insulin. My grandmother started insulin and was on dialysis a year later; I don't want that to happen to me. Instead, I'd rather just take over-the-counter naproxen to help with my new leg pain so I can walk more. Also, I don't think I need to schedule that mammogram you mentioned last time, since nobody in my family has ever had breast cancer."

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

A 55-year-old man presents to the clinic for a routine health maintenance visit. His medical history is significant for type 2 diabetes mellitus and primary hypertension. He has a 30-pack-year smoking history and continues to smoke half a pack of cigarettes daily. His surgical history is unremarkable. His last colonoscopy was performed exactly 10 years ago at age 45 and was normal. His immunizations are up to date, including an annual influenza vaccine, a Tdap booster 2 years ago, and a completed recombinant zoster vaccine series at age 50. He has never received a pneumococcal vaccine. His records show a negative one-time hepatitis C antibody test at age 50. He has no specific health complaints, new skin lesions, or vision changes today.

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 today? (Select all that apply)

A $42$-year-old woman is evaluated in the ambulatory clinic due to a three-day history of high fever, severe fatigue, and a painful sore throat. Her medical history is notable for Crohn disease, which has been in clinical remission for the past four years on a stable daily dose of azathioprine. She also has a history of recurrent gout. Three weeks ago, her primary care physician initiated febuxostat to better control her serum uric acid levels. Today, her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $98/60\text{ mmHg}$, pulse is $112/\text{min}$, and respirations are $20/\text{min}$. Physical examination reveals pale conjunctivae and several aphthous ulcers on the buccal mucosa. There is no active joint swelling, erythema, or focal source of infection identified on examination.

Laboratory studies reveal:
Leukocyte count: $1,100/\text{mm}^3$ (Absolute neutrophil count: $400/\text{mm}^3$)
Hemoglobin: $7.8\text{ g/dL}$
Platelet count: $42,000/\text{mm}^3$

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

Presenting to the nephrology clinic with a 3-day history of hand tremors, headaches, and reduced urine output, a 52-year-old male recipient of a deceased-donor renal allograft undergoes urgent evaluation. He is currently 6 months post-transplantation.

His maintenance immunosuppressive regimen includes tacrolimus, mycophenolate mofetil, and prednisone. Two weeks ago, he was diagnosed with oropharyngeal candidiasis by his primary care physician and completed a 14-day course of oral fluconazole.

Physical examination reveals a fine resting tremor in the bilateral upper extremities. The transplanted kidney is non-tender to palpation.

*Baseline serum creatinine was 1.3 mg/dL one month ago.*

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

During morning rounds, an attending physician discusses discharge planning with a 64-year-old male patient who has end-stage heart failure (New York Heart Association class IV). The patient was hospitalized four days ago for a severe exacerbation and has been stabilized on intravenous diuretics, though he continues to experience dyspnea at rest. His recent echocardiogram demonstrates a left ventricular ejection fraction of 15%, and his cardiorenal syndrome has progressed to stage 4 chronic kidney disease. The patient states, "I am tired of coming to the hospital. I know my heart is giving out. I just want to go home and be comfortable, even if it means my time is short." The physician conducts a thorough evaluation and determines that the patient clearly understands his medical condition, prognosis, and the consequences of foregoing further acute care. Later that afternoon, the patient's adult daughter, who is his emergency contact, privately tells the physician, "He is just depressed because he's been in the hospital for days. You can't let him go home to die. I want him transferred to a rehabilitation center to get stronger. I am his daughter, and I have the right to decide this." Which of the following is the most appropriate next step in the management of this patient?

An otherwise healthy 42-year-old woman visits the outpatient clinic for a scheduled check-up. She has no significant past medical history, takes no medications, and has no family history of cancer. She reports feeling completely well with no abdominal pain, bloating, or changes in bowel habits. However, she appears visibly distressed during the encounter. She states, "My best friend was just diagnosed with advanced ovarian cancer. I am terrified that I might have it too without knowing. I read online that there is a blood test for CA-125 and an ultrasound that can detect it early, and I want them done today." Which of the following is the most appropriate physician response?

Match each patient statement or scenario representing a stage in the Transtheoretical Model of Change (left) with the most appropriate physician counseling strategy (right).

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

A 71-year-old male with a history of ischemic cardiomyopathy is evaluated in the hospital. Three years ago, he received a left ventricular assist device (LVAD) as destination therapy, along with an implantable cardioverter-defibrillator (ICD). He was recently admitted with progressive jaundice, weight loss, and severe abdominal pain, and has just been diagnosed with widely metastatic pancreatic adenocarcinoma. Oncology evaluation concludes he is not a candidate for disease-directed therapy due to his poor performance status and advanced disease stage.

The patient is fully alert, conversant, and demonstrates intact decision-making capacity. He expresses a clear desire to focus exclusively on comfort, wishes to avoid any further life-prolonging or painful interventions, and wants to return home with hospice services. He emphasizes a strong fear of experiencing severe shortness of breath or painful shocks during his final days. His current hemodynamics are stable on his baseline LVAD settings, and he is not experiencing dyspnea at rest.

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

Match each palliative care clinical scenario with the most appropriate pharmacological intervention.