Patient Management

A 62-year-old woman is admitted to the oncology ward for worsening respiratory distress. She has a history of stage IV non-small cell lung cancer with extensive malignant pleural effusions. On physical examination, she is alert and fully oriented but visibly tachypneic with a respiratory rate of 34/min, utilizing accessory muscles of respiration. Despite maximal supplemental oxygen via high-flow nasal cannula, she continues to experience severe air hunger.

During a discussion with the medical team, the patient clearly articulates her understanding that her cancer is progressive and terminal. She states, "I cannot endure this struggling anymore. Please give me medication to ease my breathing, even if it means I might pass away sooner." Recognizing her severe distress and clear decision-making capacity, the attending physician initiates a continuous intravenous infusion of fentanyl to palliate her dyspnea.

Shortly afterward, the patient's husband arrives. He becomes highly agitated upon seeing the infusion pump and demands that the fentanyl be stopped immediately. He insists, "Those strong drugs will shut down her lungs! She just needs a breathing tube temporarily so her body can heal."

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

A 34-year-old woman comes to the clinic for a follow-up visit. Four weeks ago, she was diagnosed with Graves disease and was started on methimazole and propranolol. Today, she reports significant improvement in her symptoms; her palpitations have resolved, and she is sleeping much better. She has not experienced any fever or sore throat. Her blood pressure is $120/75$ mm Hg and her pulse is $72$/min. Physical examination reveals a mild, non-tender goiter but no tremors.

Laboratory results from today show:

Which of the following is the most appropriate next step in the management of this patient's antithyroid therapy?

An 81-year-old man is evaluated on hospital day 5 to determine his readiness for discharge. He was originally admitted for urosepsis complicated by severe delirium. Over the past 48 hours, he has completed a course of intravenous antibiotics and transitioned to oral therapy. His mental status has returned to his baseline, and he is alert and oriented to person, place, and time. His vital signs are temperature 37.1°C (98.8°F), blood pressure 130/80 mm Hg, pulse 76/min, and respirations 16/min. The patient's laboratory results are within normal limits. Prior to admission, he lived with his 79-year-old wife and walked independently. Currently, he is profoundly deconditioned. He requires moderate physical assistance from two people for bed-to-chair transfers and cannot ambulate. A physical therapy evaluation indicates that he participates well but experiences severe fatigue, limiting his active therapy participation to a maximum of 45 minutes per day. Which of the following is the most appropriate disposition for this patient?

A 67-year-old woman is hospitalized for an acute pulmonary embolism and has been receiving an intravenous unfractionated heparin infusion since admission. On hospital day 5, routine laboratory studies reveal a platelet count of $105,000/mm^3$, which is a significant decrease from her admission baseline of $260,000/mm^3$. Vital signs show temperature $37.1^\circ C$ ($98.8^\circ F$), blood pressure $128/76$ mmHg, heart rate $88$/min, and respiratory rate $16$/min. She denies any epistaxis, hematuria, or melena, and there is no evidence of active bleeding. However, she complains of new-onset right calf pain. Physical examination shows right calf swelling and erythema. Which of the following are appropriate next steps in the evaluation and management of this patient? (Select all that apply)

A 67-year-old biological male presents to the ambulatory clinic for a routine health maintenance evaluation. His medical history is notable for type 2 diabetes mellitus, essential hypertension, and mild osteoarthritis of the knees. His current medications include lisinopril, metformin, and atorvastatin.

He has a 45 pack-year smoking history but successfully quit smoking 17 years ago. He consumes one to two alcoholic beverages per week.

A comprehensive review of his preventive health record reveals the following:
- A screening colonoscopy performed at age 59, which revealed two 4-mm hyperplastic polyps in the sigmoid colon.
- A 2-dose series of the recombinant zoster vaccine completed at age 62.
- A single dose of the 20-valent pneumococcal conjugate vaccine (PCV20) administered at age 65.
- A seasonal inactivated influenza vaccine administered 2 weeks ago.
- A Tdap booster administered 5 years ago.

Vital signs show a blood pressure of 124/76 mmHg, heart rate of 70/min, respiratory rate of 14/min, and a body mass index of 28 kg/m². The physical examination is unremarkable.

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

A 68-year-old man is evaluated in the clinic for a 4-week history of worsening fatigue, unintentional weight loss of $4\text{ kg}$ ($8.8\text{ lb}$), and frequent palpitations. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$ and an implanted cardioverter-defibrillator (ICD) placed for secondary prevention of sustained ventricular tachycardia. His medications include amiodarone, which was started 2 years ago for frequent ICD shocks, as well as carvedilol, lisinopril, empagliflozin, and furosemide. Vital signs show a blood pressure of $130/80\text{ mmHg}$ and a heart rate of $95/\text{min}$. Physical examination reveals a fine resting tremor. The thyroid gland is normal in size, non-tender, and without palpable nodules. There is no exophthalmos. Laboratory studies reveal:

Which of the following is the most appropriate next step in the evaluation of this patient's condition to guide pharmacological management?

A 51-year-old woman comes to the ambulatory clinic to establish care. She recently changed jobs and has not seen a healthcare provider in over seven years. The patient has no acute complaints today but notes she recently entered menopause, as her last menstrual period was 14 months ago. Her past medical history is notable for mild intermittent asthma. Her body mass index is 33 kg/m². She previously smoked one pack of cigarettes daily from age 20 until she successfully quit at age 42 (22 pack-year history). She consumes one glass of wine occasionally on weekends. Vital signs today are within normal limits. Physical examination reveals a well-appearing adult with no focal abnormalities. Which of the following preventive interventions are indicated for this patient during today's visit? (Select all that apply.)

A 76-year-old man with metastatic prostate cancer and stage 4 chronic kidney disease is admitted to the hospital for management of severe, intractable bone pain. He is started on escalating doses of oral morphine. Over the next 48 hours, his pain control improves, but he develops worsening confusion, visual hallucinations, and frequent myoclonic jerks in his upper extremities. The patient's daughter, who is his designated healthcare proxy, is very distressed by these new symptoms. She demands that all opioid medications be stopped immediately, stating they are "destroying his brain." The patient is currently disoriented to time and place and cannot participate in medical decision-making. Which of the following is the most appropriate next step in management?

A 52-year-old man who is currently unhoused is evaluated for discharge on hospital day 5. He was admitted for a severe diabetic foot infection consisting of cellulitis and a 3-cm plantar ulcer, without evidence of osteomyelitis. During the hospitalization, he underwent sharp debridement of the ulcer and received intravenous antibiotics. The infection is now well-controlled, with resolving erythema and no purulence. The patient is transitioned to oral amoxicillin-clavulanate to complete a 14-day total course. He also requires daily cleaning of the ulcer with normal saline and application of a simple dry sterile dressing. His previously undiagnosed diabetes mellitus is now managed with a once-daily injection of basal insulin glargine, which he has learned to self-administer. The patient is fully independent with all activities of daily living, cognitively intact, and ambulates independently. However, the physician strongly advises him to minimize weight-bearing on the affected foot to allow the ulcer to heal. The patient usually sleeps at a congregate night-by-night emergency shelter that requires all clients to vacate the premises from 7:00 AM to 5:00 PM daily. Which of the following is the most appropriate care setting transition for this patient?

A 68-year-old woman is evaluated in the hospital on day 6 of an admission for a massive right lower extremity deep vein thrombosis. She has been treated with a continuous unfractionated heparin infusion since admission. Her past medical history includes hypertension, osteoarthritis, and type 2 diabetes mellitus. Today, she reports new-onset right arm pain and swelling at the site of a recently removed peripheral intravenous catheter.

Vital signs are within normal limits. Physical examination reveals a swollen, tender, and erythematous right upper extremity.

The patient's baseline platelet count on admission was 240,000/mm³.

Which of the following are appropriate next steps in the monitoring and management of this patient? (Select all that apply)

An 82-year-old woman with advanced Lewy body dementia is admitted to the intensive care unit with septic shock secondary to aspiration pneumonia. Over the past 48 hours, despite maximal vasopressor support and targeted antimicrobial therapy, she has developed progressive multiorgan failure, including anuric acute kidney injury and severe lactic acidosis. She is completely unresponsive to noxious stimuli, and the medical team determines her condition is terminal. She does not have a formal advance directive or a designated healthcare proxy.

Her family is present at the bedside. Her husband of 50 years, who resides in an assisted living facility due to mild cognitive impairment, clearly and consistently articulates that his wife "never wanted to be kept alive by machines with no hope of recovery." He requests the withdrawal of all life-sustaining treatments. Her oldest son, who just arrived from out of state, demands that continuous renal replacement therapy be initiated immediately, arguing that his father's memory issues invalidate his decision-making ability.

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

During an annual health maintenance visit, a 66-year-old man inquires about due screening tests. He has a history of mild knee osteoarthritis managed with intermittent ibuprofen. His last colonoscopy, performed 5 years ago, was unremarkable. At last year's visit, he received the 20-valent pneumococcal conjugate vaccine (PCV20) and completed his recombinant zoster vaccine series. Recent laboratory studies, including a lipid panel and hemoglobin A1c, are within normal limits. The patient mentions that he briefly smoked cigarettes during a single summer while in college, estimating he consumed roughly ten packs in total before quitting permanently. He currently drinks one glass of wine weekly and walks daily. Vital signs and physical examination show no abnormalities. Which of the following is the most appropriate preventive intervention for this patient at this time?

Evaluate the following patient clinical profiles and pair each individual with the most appropriate, guideline-concordant preventive care intervention.

A 65-year-old man with a 40-pack-year smoking history presents to the clinic for a routine health maintenance visit. He has no symptoms of lung disease. The physician initiates a discussion regarding lung cancer screening with low-dose computed tomography (LDCT) and employs the SHARE approach for shared decision-making. Arrange the following physician statements in the correct sequential order according to the steps of the SHARE protocol.

A 45-year-old man is hospitalized for native mitral valve infective endocarditis due to methicillin-susceptible Staphylococcus aureus. He has been receiving intravenous cefazolin for the past week. He is now afebrile, his surveillance blood cultures are negative, and he is deemed medically stable. The multidisciplinary team decides to transition him to Outpatient Parenteral Antimicrobial Therapy (OPAT) to complete his remaining 5-week course of antibiotics at home. Arrange the following discharge planning and care transition steps in the most appropriate chronological sequence to ensure a safe transition to the home setting.

A 34-year-old woman comes to the clinic to discuss contraception. She is entering a new relationship and requests a prescription for a combined oral contraceptive pill. Her medical history is notable for an unprovoked deep vein thrombosis in her right lower extremity 3 years ago, for which she completed a 6-month course of rivaroxaban. She currently takes no medications and does not smoke. The physician informs the patient that estrogen-containing contraceptives are medically contraindicated due to her history. The patient becomes frustrated and states, "I was on the pill for 10 years before my blood clot without any problems, and I know my own body. I am willing to accept the risk of another clot. It is my body and my choice, so please just write the prescription." Which of the following is the most appropriate response by the physician?

Match each patient's clinical presentation and associated risk stratification score with the most appropriate immediate disposition from the Emergency Department.

A physician evaluates a 68-year-old male patient who is visiting the clinic for a general check-up. The patient has a documented medical history of type 2 diabetes mellitus, essential hypertension, and hyperlipidemia, all of which are well-controlled with his current medications.

He is a former heavy smoker. He smoked 1.5 packs of cigarettes daily from age 18 until he successfully quit at age 52. He drinks alcohol occasionally and exercises three times a week. He has no personal history of cardiovascular disease.

A review of his health records shows that he underwent a screening colonoscopy at age 61, which was completely normal. His immunization records indicate he received the 20-valent pneumococcal conjugate vaccine at age 66, a Tdap booster at age 64, and an age-appropriate influenza vaccine two weeks ago. Recent laboratory studies, including a comprehensive metabolic panel, hemoglobin A1c, and a urine albumin-to-creatinine ratio, were performed last month and were all within target ranges.

The patient feels well and has no active complaints. His blood pressure is 126/78 mm Hg, heart rate is 72/min, and BMI is $28\text{ kg/m}^2$. Physical examination reveals normal heart sounds, clear lungs bilaterally, and a soft, non-tender abdomen with no palpable masses or bruits.

Based on current guidelines, which of the following is the most appropriate next step in preventive care for this patient?

A 45-year-old man presents to the outpatient clinic for a routine health maintenance visit. His blood pressure is 138/86 mm Hg and his heart rate is 76/min. The physician is preparing to initiate a structured tobacco cessation intervention utilizing the United States Preventive Services Task Force (USPSTF) recommended "5 A's" clinical protocol. Arrange the following physician statements in the correct chronological sequence to appropriately execute this framework.

A 74-year-old man with end-stage idiopathic pulmonary fibrosis is receiving home hospice care. He develops an acute, severe episode of dyspnea at rest, accompanied by marked distress and tachypnea. He is already receiving supplemental oxygen. Arrange the following palliative interventions for terminal dyspnea in the most appropriate stepwise order of escalation, from the initial measure (first) to the intervention of last resort (last).