Patient Management

A $45$-year-old man comes to the emergency department due to a $2$-day history of worsening left leg swelling and pain. He was diagnosed with active pulmonary tuberculosis three weeks ago and is currently in the intensive phase of treatment with rifampin, isoniazid, pyrazinamide, and ethambutol. He also has a history of HIV, for which he takes dolutegravir $50\text{ mg}$ twice daily, tenofovir alafenamide, and emtricitabine. His viral load is undetectable, and his CD4 count is $450/\text{mm}^3$. Vital signs are within normal limits. Physical examination reveals unilateral edema, erythema, and tenderness of the left calf. Laboratory studies show a serum creatinine of $0.9\text{ mg/dL}$ and normal liver function tests. A duplex ultrasound of the left lower extremity demonstrates a noncompressible, acute thrombus in the left popliteal and femoral veins. Which of the following is the most appropriate pharmacologic intervention for managing this patient's deep vein thrombosis?

Evaluate the following patient encounters. Match each clinical vignette to the single most appropriate next best step in preventive care and screening.

Review the following patient clinical profiles and match each with the single most appropriate next step in preventive care or screening based on current evidence-based guidelines.

A 42-year-old man comes to the clinic for follow-up of difficult-to-control hypertension. He has a 5-year history of elevated blood pressure that remains poorly controlled despite adherence to maximal tolerated doses of amlodipine, lisinopril, and chlorthalidone. Today, his blood pressure is 168/100 mmHg. Routine laboratory testing reveals a serum potassium concentration of 3.0 mEq/L and a serum sodium concentration of 144 mEq/L. He takes no other medications or over-the-counter supplements. The physician suspects a specific endocrine etiology for his secondary hypertension.

Arrange the following diagnostic steps for the suspected condition in the most appropriate sequential order, from initial screening to preoperative evaluation.

A 55-year-old man with a history of alcohol-associated cirrhosis is rushed to the triage bay by paramedics following multiple episodes of massive hematemesis at his residence. On physical examination, the patient is obtunded, pooling blood in the oropharynx, and withdraws only to painful stimuli. Vital signs show a heart rate of 134/min, blood pressure of 72/38 mm Hg, respiratory rate of 28/min, and oxygen saturation of 89% on room air. Arrange the following acute management steps in the most appropriate chronological order for this patient's initial stabilization.

A 28-year-old construction worker is transported to the trauma bay via helicopter after being crushed beneath a collapsed concrete retaining wall. On arrival, he is moaning and visibly pale but follows simple commands. His airway is patent, and breath sounds are equal bilaterally. Vital signs show a temperature of 36.2°C (97.2°F), blood pressure of 72/40 mmHg, pulse of 138/min, and respiratory rate of 26/min. Oxygen saturation is 95% on high-flow oxygen. Primary survey reveals massive ecchymoses over the lower abdomen, flanks, and perineum. On gentle palpation, the pubic symphysis feels widely diastatic. There is a small amount of blood visible at the urethral meatus. No obvious external hemorrhage is noted on the extremities or torso. Which of the following interventions should be ordered simultaneously as the initial management for this patient? (Select 2)

A 61-year-old woman is admitted to the hospital with a 4-day history of high-grade fevers, a nonproductive cough, and right-sided pleuritic chest pain. She underwent an orthotopic liver transplant 7 months ago for primary biliary cholangitis. Her home medications include tacrolimus, mycophenolate mofetil, and low-dose prednisone. Vital signs show a temperature of 38.8°C (101.8°F), blood pressure of 118/74 mm Hg, pulse of 102/min, and respiratory rate of 20/min. Pulse oximetry is 96% on room air. Laboratory studies reveal a serum creatinine of 1.1 mg/dL and normal liver function tests. A non-contrast computed tomography scan of the chest demonstrates a 3-cm nodular opacity in the right upper lobe surrounded by a halo of ground-glass attenuation. Serum galactomannan assay is strongly positive. The medical team plans to initiate intravenous voriconazole therapy. Which of the following is the most appropriate management step regarding this patient's pharmacologic regimen?

A 45-year-old woman is brought to the emergency department due to altered mental status, high fever, and severe agitation. Her husband reports she has a history of Graves disease but stopped taking her medications three months ago. On physical examination, her temperature is 39.8°C (103.6°F), blood pressure is 160/70 mmHg, and heart rate is 145/min and irregular. She is visibly tremulous, diaphoretic, and delirious. An electrocardiogram confirms atrial fibrillation with a rapid ventricular response. A diagnosis of thyroid storm is suspected.

Which of the following pharmacologic interventions are appropriate components of the immediate management of this patient? (Select all that apply)

A 64-year-old man is brought to the emergency department by paramedics after his wife found him lethargic and confused at home. She reports that he had been complaining of progressive, severe upper abdominal pain and nausea over the past three days. His past medical history is significant for osteoarthritis, for which he takes high-dose ibuprofen daily, and hypertension. On physical examination, the patient is obtunded and profusely diaphoretic. Temperature is 39.4°C (102.9°F), blood pressure is 72/40 mmHg, pulse is 132/min, and respirations are 28/min. Pulse oximetry is 93% on room air. Cardiopulmonary examination reveals tachycardia with distant heart sounds and rapid, shallow breathing. Abdominal examination demonstrates a rigid, board-like abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Which of the following is the most appropriate initial step in the management of this patient?

Emergency medical responders transport a $71$-year-old female to the acute care bay due to the abrupt onset of crushing substernal chest pain and profound respiratory distress. Her husband reports that she experienced a myocardial infarction $3$ days ago but eloped from the hospital against medical advice. On examination, the patient is somnolent, cyanotic, and exhibits severe suprasternal retractions. Copious pink, frothy secretions are pooling in her oropharynx. Auscultation reveals a harsh, blowing holosystolic murmur at the cardiac apex and diffuse coarse crackles throughout both lung fields. Vital signs include a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate of $132\text{/min}$, blood pressure of $72/42\text{ mm Hg}$, and respiratory rate of $36\text{/min}$. Pulse oximetry shows an oxygen saturation of $81\%$ on room air. Which of the following represents the most critical immediate intervention for this patient?

A $68$-year-old woman is hospitalized for an acute exacerbation of chronic obstructive pulmonary disease (COPD). Her baseline $\text{FEV}_1$ is $35\%$ of predicted. Over the past $48$ hours, she has been receiving intravenous methylprednisolone, nebulized ipratropium-albuterol, and non-invasive positive pressure ventilation. On hospital day $3$, her respiratory status has improved, and she is transitioned to nasal cannula oxygen. However, she begins to complain of new-onset palpitations. Vital signs show a blood pressure of $122/78 \text{ mmHg}$ and a heart rate of $128/\text{min}$. A $12$-lead electrocardiogram demonstrates an irregular rhythm with three distinct P-wave morphologies in the same lead and an irregular PR interval. Laboratory studies show a serum potassium of $4.2 \text{ mEq/L}$ and a serum magnesium of $2.1 \text{ mg/dL}$. Which of the following is the most appropriate pharmacologic intervention to manage this patient's arrhythmia?

Determine the optimal post-acute care setting for each of the described patients based on their current clinical stability, rehabilitation potential, and goals of care.

A 72-year-old man is hospitalized following a massive left middle cerebral artery ischemic stroke. His acute hospital course has stabilized, but he has significant residual right-sided hemiparesis and expressive aphasia. The primary care team is initiating the discharge planning process. His family is highly supportive but expresses uncertainty regarding their ability to provide the necessary level of care at home.

Arrange the following steps of the multidisciplinary disposition and care transition process in the most appropriate chronological order, from first to last.

The selection of a post-acute care environment depends heavily on medical complexity, caregiver availability, and the intensity of rehabilitation therapy a patient can safely tolerate. Match each of the following patient clinical profiles to the most appropriate discharge destination.

A $78$-year-old woman is brought to the emergency department by her neighbor due to cough, fever, and generalized weakness. The neighbor found the patient on the floor of her apartment, stating she had fallen $12$ hours earlier when trying to get to the bathroom and was too weak to get back up. The patient has a $3$-day history of a productive cough. Medical history includes hypertension, osteoporosis, and moderate osteoarthritis of the knees. She lives alone.

On physical examination, temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $92$/min, blood pressure is $135/85$ mm Hg, and respirations are $20$/min. Pulse oximetry shows $95\%$ on room air. She is alert and oriented to person, place, and time. Lung auscultation reveals crackles in the left lower lobe. There is no evidence of trauma or fracture from the fall, but she exhibits profound generalized weakness. Physical therapy evaluation in the emergency department demonstrates she is currently unable to ambulate and requires moderate assistance from two people to transfer from the bed to a chair.

Laboratory studies show:
Leukocyte count: $11,500/\text{mm}^3$
Blood urea nitrogen: $16$ mg/dL
Serum creatinine: $0.9$ mg/dL

A chest radiograph confirms a left lower lobe consolidation. Intravenous hydration and empiric oral antibiotics are initiated.

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

Match each challenging patient counseling scenario (left) with the most appropriate initial physician communication strategy (right).

A 48-year-old man is evaluated in the emergency department for sudden-onset right-sided chest pain and mild shortness of breath that began earlier this morning. His medical history is significant for hypertension and severe alcohol use disorder. He is currently unhoused and sleeps at a local congregate shelter. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $135/85\text{ mmHg}$, pulse $92\text{/min}$, and respiratory rate $18\text{/min}$. Oxygen saturation is $96\%$ on room air. On physical examination, he is alert and oriented but appears mildly disheveled. The lungs are clear to auscultation bilaterally, and there is no right ventricular heave.

Computed tomography pulmonary angiography demonstrates a segmental pulmonary embolism in the right lower lobe. Laboratory studies show a serum troponin I level of $< 0.01\text{ ng/mL}$ (normal $< 0.04\text{ ng/mL}$), an NT-proBNP level of $80\text{ pg/mL}$ (normal $< 125\text{ pg/mL}$), and a serum creatinine of $0.9\text{ mg/dL}$. His Pulmonary Embolism Severity Index (PESI) score is calculated to be $58$ (Class I, very low risk).

During the evaluation, the patient admits to drinking approximately one pint of vodka daily. He also mentions that his backpack, which contained his hypertension medications, was stolen at the shelter two days ago. He states that he feels much better after receiving a dose of intravenous acetaminophen and expresses a strong desire to leave the emergency department immediately to secure a bed at the shelter for the night.

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

A 52-year-old woman comes to the clinic for a routine health maintenance examination. She has a history of mild hypertension well-controlled on lisinopril. She has no gastrointestinal symptoms, no changes in bowel habits, and no family history of cancer. The physician recommends initiating colorectal cancer screening. The patient appears visibly anxious and states, "I really do not want to have a colonoscopy or any other screening test. My neighbor had a colonoscopy last year and ended up in the hospital with a punctured bowel. Can I just skip this? I eat a very healthy diet and feel perfectly fine."

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

A $54$-year-old woman is evaluated in the hospital on day 3 of admission for severe fatigue, jaundice, and right upper quadrant discomfort. She has a history of metastatic melanoma and received her third cycle of ipilimumab and nivolumab three weeks prior to admission.

On admission, her viral hepatitis panel and autoimmune markers (antinuclear antibody, anti-smooth muscle antibody) were negative. A right upper quadrant ultrasound showed normal liver echotexture with no biliary dilation and normal flow in the portal and hepatic veins. She was diagnosed with Grade 3 immune-checkpoint inhibitor-induced hepatitis. Immunotherapy was permanently discontinued, and intravenous methylprednisolone $2\text{ mg/kg/day}$ was initiated.

Currently, 72 hours later, the patient reports no improvement in her symptoms. Her vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse $88/\text{min}$, and blood pressure $118/74\text{ mmHg}$.

Serial laboratory values are shown below:

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

During an outpatient consultation, a 42-year-old woman discusses the possibility of undergoing BRCA1/2 genetic testing due to a profound family history of early-onset breast and ovarian cancer. Throughout the encounter, she voices several specific hesitations. Match each of the patient's expressed barriers to testing (left) with the most targeted and appropriate physician counseling strategy (right).