Patient Management

A 48-year-old woman comes to the clinic for a routine health maintenance visit. She was diagnosed with chronic hepatitis C virus (HCV) infection 6 years ago. At the time of diagnosis, transient elastography demonstrated a liver stiffness of $16 \text{ kPa}$, consistent with compensated cirrhosis. She was subsequently treated with a 12-week course of direct-acting antivirals and achieved a sustained virologic response (cure) 5 years ago. She has no history of ascites, hepatic encephalopathy, or variceal bleeding.

She feels well and has no current symptoms. She takes no medications and does not use alcohol, tobacco, or illicit drugs.

Vital signs are within normal limits. Physical examination reveals a palpable, firm liver edge but no splenomegaly, jaundice, or stigmata of chronic liver disease.

Her most recent screening mammogram 6 months ago was normal. Her last colonoscopy at age 45 was normal.

Vaccination history includes a complete hepatitis A and B series, the 20-valent pneumococcal conjugate vaccine (PCV20) 2 years ago, Tdap 3 years ago, and the annual influenza vaccine.

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

A 20-year-old male college student comes to the university health clinic for a follow-up visit. He has a history of moderate persistent asthma and was treated in the emergency department two weeks ago for a severe exacerbation. At a clinic visit two months ago, he was prescribed a daily inhaled corticosteroid (budesonide) and an as-needed short-acting beta-agonist (albuterol). Today, the patient reports using his rescue inhaler almost every day but admits he has not used the daily preventative inhaler. When asked about this discrepancy, the patient states, 'I refuse to take a daily steroid. I am training hard to make the regional track and field team, and I absolutely cannot risk getting disqualified for doping or gaining a bunch of unnatural muscle mass.'

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

Match each clinical presentation in the palliative care setting with the most appropriate next step in management.

A 52-year-old woman with a 30-pack-year smoking history and poorly controlled hypertension presents to the clinic for a follow-up visit. During the encounter, the physician utilizes principles of Motivational Interviewing and patient-centered communication to discuss lifestyle modifications. Match each physician communication technique to the specific statement that best demonstrates its clinical application.

During a scheduled annual health review, a 46-year-old female patient voices deep concerns about her familial cancer risk. She notes that her mother received a diagnosis of epithelial ovarian cancer one month ago at the age of 68. Furthermore, her maternal aunt was treated for breast cancer diagnosed at age 52. Her medical background includes uncomplicated essential hypertension managed with lisinopril. Preventive care records demonstrate a negative screening colonoscopy performed 14 months ago, a negative digital mammogram completed 3 months ago, and a normal cervical cytology with negative high-risk human papillomavirus (HPV) co-testing conducted 2 years prior. Today's physical assessment, including a comprehensive clinical breast examination, reveals no abnormalities. Vital signs are within normal limits. Based on current evidence-based guidelines, which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man presents to the clinic for a health maintenance examination. He recently applied for a life insurance policy and was required to undergo a comprehensive metabolic panel. The patient brings the laboratory report, which shows a total bilirubin level of 1.7 mg/dL with a direct bilirubin of 0.2 mg/dL. The remainder of the panel, including aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase, is within normal limits. A complete blood count and reticulocyte count are normal. The patient appears visibly agitated, pacing the examination room. He states, "My uncle died a painful death from liver cancer last year. I read online that high bilirubin means the liver is failing. Do I need chemotherapy or a transplant?" Which of the following is the most appropriate initial response by the physician?

A 68-year-old man presents to the ambulatory clinic to establish care. He recently relocated and states he has not seen a healthcare provider or had any medical screenings in over 10 years. His past medical history is significant for hypertension and hyperlipidemia. He has a 40-pack-year smoking history but successfully quit smoking 18 years ago. He currently takes amlodipine and atorvastatin. Vital signs show a blood pressure of 128/78 mmHg, heart rate of 72/min, and a BMI of 27 kg/m $^2$. Physical examination is unremarkable. Which of the following preventive interventions are indicated for this patient at today's visit? (Select all that apply)

During difficult clinical encounters, physicians frequently utilize the NURSE framework to respond empathetically to patient emotions. An oncologist is delivering a new diagnosis of advanced malignancy to several different patients, each of whom responds with a strong emotional reaction. Match each patient's emotional statement to the most appropriate physician empathetic response technique.

A 31-year-old woman is evaluated in the neurology clinic to discuss escalating her disease-modifying therapy. She has a 4-year history of relapsing-remitting multiple sclerosis. Despite strict adherence to glatiramer acetate, she has experienced three distinct clinical relapses over the past year. A recent magnetic resonance imaging (MRI) scan of the brain and cervical spine reveals multiple new T2-hyperintense and gadolinium-enhancing lesions. The physician decides to transition her to oral fingolimod. She has a remote history of an appendectomy but is otherwise healthy. Vital signs are normal. Which of the following baseline assessments and initiation protocols are strictly required to ensure the safe administration of this specific medication? (Select exactly 2 options)

A 42-year-old woman presents to the ambulatory clinic for a routine wellness examination. She has not seen a physician in four years. The patient has no specific health complaints. Her medical history is significant only for mild allergic rhinitis, for which she takes over-the-counter cetirizine as needed. Menarche occurred at age 12, and she is nulliparous. She currently uses an oral contraceptive pill. Family history is notable for her maternal grandmother being diagnosed with breast cancer at age 78. She drinks one glass of wine on weekends and has never smoked. Vital signs are within normal limits. Physical examination reveals soft, non-tender breasts with no palpable masses, skin dimpling, axillary lymphadenopathy, or nipple discharge. She has never undergone breast imaging. Which of the following is the most appropriate next step in preventive care for this patient?

A $62$-year-old man presents to the outpatient clinic for a follow-up visit. Three days ago, he was evaluated in the emergency department for right calf pain and swelling. A venous compression ultrasound confirmed an acute, unprovoked deep vein thrombosis in the right popliteal vein. He was started on oral apixaban monotherapy and discharged. He has a history of essential hypertension and osteoarthritis. His current medications include apixaban, lisinopril, and acetaminophen. He feels well today, and his right leg swelling has mildly improved. His blood pressure is $128/78$ mmHg, heart rate is $72$/min, and respiratory rate is $14$/min. Which of the following parameters are strictly recommended to obtain at baseline and for periodic monitoring during this patient's ongoing anticoagulant therapy? (Select all that apply)

A 68-year-old man is evaluated in the intensive care unit for decreased urine output. He was admitted 8 days ago for a severe exacerbation of chronic obstructive pulmonary disease requiring endotracheal intubation and mechanical ventilation. On hospital day 5, he developed a fever, increased oxygen requirements, and new infiltrates on chest radiography. Endotracheal aspirate cultures subsequently grew Methicillin-resistant Staphylococcus aureus (MRSA), and he was started on intravenous vancomycin. Today, his urine output over the past 24 hours has been 350 mL. Temperature is 37.8°C (100.0°F), blood pressure is 110/70 mm Hg, and pulse is 92/min. Laboratory studies show a serum blood urea nitrogen of 48 mg/dL and a serum creatinine of 3.2 mg/dL (baseline was 1.1 mg/dL upon admission). The serum vancomycin trough level is 34 mcg/mL (therapeutic range: 15-20 mcg/mL). The physician decides to discontinue vancomycin due to acute kidney injury. Which of the following is the most appropriate alternative pharmacologic intervention to treat this patient's pulmonary infection?

A 54-year-old male is preparing for transfer to a skilled nursing facility (SNF) following a prolonged 28-day hospitalization for necrotizing pancreatitis. His hospital course was complicated by critical illness polyneuropathy and newly insulin-dependent diabetes mellitus. The multidisciplinary team has cleared him for discharge, and the case manager has secured an available bed at the SNF for today.

To ensure a safe care transition and adhere to standardized patient handoff protocols, arrange the following transitional care steps in the most appropriate chronological sequence.

A male patient, aged $42$, presents to his primary care provider with a $3$-month history of excessive urination and an unquenchable thirst, requiring him to consume over $5$ liters of water daily. He has a $10$-year history of bipolar I disorder, which has been well-controlled on lithium carbonate. Two prior attempts by his psychiatrist to taper the lithium and transition to alternative mood stabilizers resulted in severe manic episodes requiring involuntary inpatient hospitalizations. His current blood pressure is $118/76\text{ mmHg}$ and heart rate is $82\text{/min}$. Laboratory evaluation reveals:

Serum sodium: $146\text{ mEq/L}$
Serum potassium: $4.1\text{ mEq/L}$
Serum creatinine: $1.0\text{ mg/dL}$
Serum lithium: $0.8\text{ mEq/L}$ (therapeutic range: $0.6-1.2\text{ mEq/L}$)
Urine specific gravity: $1.003$
Urine osmolality: $140\text{ mOsm/kg H}_2\text{O}$

During the evaluation, the administration of exogenous desmopressin results in a repeat urine osmolality of $145\text{ mOsm/kg H}_2\text{O}$.

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

A 52-year-old man presents to the clinic for a routine follow-up of hypertension that has been difficult to control. Despite adherence to maximum tolerated doses of amlodipine, lisinopril, and doxazosin, his blood pressure today is 162/98 mm Hg. The patient reports no headaches, palpitations, or diaphoresis. Laboratory studies show a serum potassium of 3.9 mEq/L and a serum sodium of 142 mEq/L. Suspecting a secondary cause of hypertension, the physician orders a screening panel which reveals a plasma aldosterone concentration of 22 ng/dL and a plasma renin activity of 0.5 ng/mL/hr (aldosterone-to-renin ratio = 44). Which of the following is the most appropriate next step in the diagnostic workup?

A 27-year-old man is brought to the emergency department after a high-speed motorcycle collision. On arrival, he is obtunded, and his airway is immediately secured via endotracheal intubation. Vital signs are temperature 34.8°C (94.6°F), heart rate 145/min, and blood pressure 65/40 mmHg. Breath sounds are equal bilaterally, and a portable chest radiograph is unremarkable. The pelvis is mechanically stable. An extended focused assessment with sonography for trauma (eFAST) scan shows a large amount of free fluid in the hepatorenal and splenorenal spaces, with no pericardial effusion. A massive transfusion protocol is initiated.

Arrange the following surgical and procedural interventions in the most appropriate chronological order for this patient's definitive management.

A 47-year-old male agricultural worker is brought to the emergency department by his supervisor due to sudden onset of confusion, severe vomiting, and labored breathing. The symptoms began approximately 45 minutes ago while he was spraying pesticides in an enclosed greenhouse. The patient is lethargic, diaphoretic, and drooling copiously. His temperature is 36.8°C (98.2°F), blood pressure is 95/55 mm Hg, pulse is 42/min, and respirations are 28/min. Pulse oximetry shows 86% on room air. Physical examination reveals bilateral miosis, diffuse pulmonary wheezing, and visible muscle fasciculations in the upper extremities. The patient is coughing up large amounts of frothy sputum. Which of the following is the single most urgent initial step in the management of this patient?

A 77-year-old man is evaluated in the emergency department for a 3-day history of worsening cough, subjective fevers, and mild shortness of breath. His medical history includes hypertension, benign prostatic hyperplasia, and mild osteoarthritis.

Vital signs are temperature $38.0^{\circ}\text{C}$ ($100.4^{\circ}\text{F}$), heart rate $88/\text{min}$, blood pressure $130/80 \text{ mmHg}$, respiratory rate $20/\text{min}$, and oxygen saturation $95\%$ on room air. Physical examination reveals an alert and cooperative patient. Lung auscultation reveals crackles in the left lower lung field.

Laboratory results:
Leukocytes: $11,200/\text{mm}^3$
Blood urea nitrogen: $18 \text{ mg/dL}$
Creatinine: $1.0 \text{ mg/dL}$

A chest radiograph demonstrates patchy consolidation in the left lower lobe. He is diagnosed with community-acquired pneumonia. A calculated Pneumonia Severity Index (PSI) places him in Risk Class II, and his CURB-65 score is $1$ (for age $\geq 65$).

During the evaluation, the patient attempts to ambulate to the bathroom but requires the assistance of two nurses due to profound generalized weakness and unsteadiness. He states he has barely eaten or consumed fluids for 3 days because he has been too weak to get out of bed. He lives alone in a second-floor apartment, and his only child lives in another country.

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

A 68-year-old retired teacher is admitted to the cardiac telemetry unit for the elective initiation of dofetilide to maintain normal sinus rhythm after a recent electrical cardioversion for symptomatic atrial fibrillation. He has a history of hypertension and ischemic cardiomyopathy. His home medications include lisinopril, metoprolol succinate, and apixaban. His vital signs are stable, and the physical examination is unremarkable. The care team is planning the mandatory safety protocol for initiating this antiarrhythmic therapy.

Arrange the following clinical steps in the correct chronological sequence for the initiation, monitoring, and evaluation of dofetilide therapy in this patient.

Paramedics arrive at the emergency department with a $72$-year-old gentleman who experienced a sudden syncopal episode at his residence. Upon regaining consciousness in transit, he complained of excruciating, tearing pain radiating from his mid-abdomen to his lower back. His past medical history is significant for hypertension, hyperlipidemia, tobacco use disorder, and a $4.8$-cm infrarenal abdominal aortic aneurysm identified on ultrasound $18$ months ago. Upon arrival, he is lethargic, pale, and profoundly diaphoretic. Vital signs show a temperature of $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), heart rate of $138$/min, respiratory rate of $26$/min, and blood pressure of $72/42$ mm Hg. Cardiopulmonary auscultation is unremarkable. Abdominal examination reveals a tender, pulsatile midline mass. Both lower extremities are cool with barely palpable dorsalis pedis pulses. Intravenous access is secured with two large-bore catheters, and uncrossmatched blood transfusion is initiated. Which of the following is the most appropriate next step in management?