Patient Management

A 62-year-old man presents to the clinic for a routine health maintenance visit. His medical history is significant for type 2 diabetes mellitus and stage 3a chronic kidney disease. He smoked one pack of cigarettes daily from age 20 to 50, but quit 12 years ago. He is currently asymptomatic and reports good medication adherence.

His preventive care history includes the following:
- Colonoscopy at age 55 revealed no polyps or abnormalities.
- Recombinant zoster vaccine series was completed at age 55.
- Tetanus, diphtheria, and acellular pertussis (Tdap) booster was administered 5 years ago.
- Annual influenza and updated COVID-19 vaccines were administered last month.
- One-time hepatitis C antibody screening was negative 3 years ago.
- He has never received any pneumococcal vaccinations.

Physical examination is unremarkable. Which of the following preventive interventions are currently indicated for this patient? (Select all that apply)

A 28-year-old man with type 1 diabetes mellitus is receiving care in the intensive care unit for severe diabetic ketoacidosis. He is currently being managed with intravenous fluid resuscitation and a continuous intravenous regular insulin infusion. Arrange the following clinical milestones and monitoring-based interventions in the correct chronological sequence required for a safe transition to maintenance subcutaneous therapy.

During a scheduled annual wellness examination, a 60-year-old woman is evaluated in the primary care clinic. She feels well and has no acute complaints. Her medical history is notable for seropositive rheumatoid arthritis, which has been well-controlled on a stable regimen of adalimumab and methotrexate for the past four years. She has a 10 pack-year smoking history, currently smoking half a pack of cigarettes daily. Her family history is significant for her mother being diagnosed with breast cancer at age 72 and her father having a stroke at age 80.

Review of her preventive health record reveals the following:
- Screening colonoscopy at age 52 was normal.
- Screening mammography 6 months ago was normal.
- Pap smear with human papillomavirus (HPV) co-testing 2 years ago was normal.
- Hepatitis C virus antibody test 1 year ago was negative.

Her immunizations are up to date, including a 20-valent pneumococcal conjugate vaccine (PCV20) at age 58, two doses of the recombinant zoster vaccine at age 50, and an inactivated influenza vaccine 3 weeks ago.

Her body mass index is 21 kg/m². Physical examination shows no joint effusions, tenderness, or deformities.

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

Match each clinical scenario evaluated in the primary care setting with the most appropriate, evidence-based preventive care intervention.

A 38-year-old man is evaluated in the hospital on day 4 of admission for an acute left lower extremity deep vein thrombosis. He has a known history of primary antiphospholipid syndrome. Upon admission, he was started on a continuous intravenous unfractionated heparin infusion and oral warfarin.

Daily INR values since admission are as follows:

Today's laboratory results show an activated partial thromboplastin time (aPTT) of 68 seconds (therapeutic goal: 60-80 seconds). His platelet count is 210,000/mm³ (baseline 225,000/mm³ on admission). The patient reports that his leg swelling has significantly improved, though he still experiences mild residual leg pain. He has no signs of clinical bleeding.

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

A 64-year-old man presents to the clinic for a health maintenance examination. He feels well and has no history of cardiovascular disease, chest pain, shortness of breath, or transient ischemic attacks. His medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus. Current medications include lisinopril, metformin, and atorvastatin. Blood pressure is 128/78 mm Hg, and heart rate is 72/min. Recent laboratory studies show a hemoglobin A1c of 7.1% and an LDL cholesterol of 85 mg/dL. His calculated 10-year atherosclerotic cardiovascular disease (ASCVD) risk is 14%. The patient read a health newsletter recommending daily aspirin to prevent heart attacks and asks if he should start taking it. Which of the following is the most appropriate recommendation regarding antiplatelet therapy for this patient?

A 59-year-old woman is admitted to the hospital with a 4-day history of worsening abdominal distention, increased lethargy, and confusion. She has a history of cirrhosis secondary to nonalcoholic steatohepatitis.

Home medications:
Spironolactone $100\text{ mg}$ daily
Furosemide $40\text{ mg}$ daily
Nadolol $40\text{ mg}$ daily

Vitals:
Temperature: $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$)
Blood pressure: $96/54\text{ mmHg}$
Pulse: $108/\text{min}$
Respirations: $18/\text{min}$

Physical examination reveals scleral icterus and a distended abdomen with shifting dullness and diffuse mild tenderness to palpation. Neurologic examination is notable for lethargy, disorientation to time and place, and a bilateral flapping tremor of the hands when the wrists are extended.

Laboratory results:
Hemoglobin: $10.2\text{ g/dL}$
Platelet count: $78,000/\text{mm}^3$
Leukocyte count: $11,500/\text{mm}^3$
Sodium: $131\text{ mEq/L}$
Potassium: $3.4\text{ mEq/L}$
Blood urea nitrogen: $38\text{ mg/dL}$
Creatinine: $1.8\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$)
Total bilirubin: $4.2\text{ mg/dL}$
International normalized ratio (INR): $1.9$

Diagnostic paracentesis is performed, yielding cloudy yellow fluid. Ascitic fluid analysis reveals an absolute neutrophil count of $450/\text{mm}^3$.

Which of the following pharmacologic interventions should be initiated in this patient? (Select all that apply)

A 72-year-old woman is brought to the emergency department by her daughter due to a 2-day history of persistent nausea, vomiting, and profound generalized weakness. The patient also reports seeing "yellow halos" around lights in her home. Her medical history includes heart failure with reduced ejection fraction, atrial fibrillation, and hypertension. Her daily medications are digoxin, furosemide, lisinopril, and rivaroxaban. Vital signs show a heart rate of 48/min and blood pressure of 105/65 mm Hg. Physical examination reveals a lethargic woman with dry mucous membranes.

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

A $68$-year-old man is evaluated on hospital day $3$ for acute decompensated heart failure. On admission, he had severe dyspnea, orthopnea, and $3+$ bilateral lower extremity edema. He was initiated on intravenous bumetanide. Over the past $48$ hours, his total urine output has been $6,500\text{ mL}$, and his weight has decreased from $92\text{ kg}$ to $86\text{ kg}$. Today, the patient reports significant improvement in his breathing and is able to lie flat comfortably. Physical examination shows clear lungs bilaterally and trace lower extremity edema. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $112/70\text{ mmHg}$, and heart rate $82/\text{min}$.

Laboratory studies today:
Blood urea nitrogen: $54\text{ mg/dL}$ (baseline $24\text{ mg/dL}$)
Serum creatinine: $2.3\text{ mg/dL}$ (baseline $1.2\text{ mg/dL}$)

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

A 74-year-old man is brought to the clinic by his son for a routine health maintenance visit. The patient has a history of severe chronic obstructive pulmonary disease requiring continuous home oxygen, New York Heart Association class IV heart failure, and stage 4 chronic kidney disease. Over the past 12 months, he has been hospitalized four times for cardiopulmonary exacerbations. He is wheelchair-bound and requires assistance with most activities of daily living. He has a 55 pack-year smoking history and continues to smoke several cigarettes daily. His most recent preventive screenings included a normal colonoscopy at age 64 and a negative low-dose chest computed tomography scan 2 years ago. The son asks which cancer screenings his father should undergo today. Which of the following is the most appropriate recommendation?

A $58$-year-old man presents to the emergency department with a $2$-day history of nausea, vomiting, abdominal pain, and poor oral intake. He has a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia. His medications include metformin, dapagliflozin, lisinopril, and atorvastatin.

Temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $102/64$ mmHg, pulse is $112$/min, and respirations are $24$/min. Physical examination shows dry mucous membranes and diffuse mild abdominal tenderness without rebound or guarding.

Laboratory studies show:
Na $^+$: $132$ mEq/L
K $^+$: $4.8$ mEq/L
Cl $^-$: $98$ mEq/L
HCO $_3^-$: $14$ mEq/L
Urea nitrogen (BUN): $38$ mg/dL
Creatinine: $1.6$ mg/dL
Glucose: $185$ mg/dL
Ketones: Positive

Arterial blood gas on room air:
pH: $7.24$
pCO $_2$: $28$ mmHg
pO $_2$: $95$ mmHg

Which of the following intravenous regimens is the most appropriate pharmacologic management for this patient?

For each patient presenting to the ambulatory primary care clinic for a health maintenance examination, select the most appropriate guideline-concordant preventive screening or intervention.

A 42-year-old woman is brought to the emergency department by her husband due to severe confusion, agitation, and recurrent vomiting for the past 24 hours. She was diagnosed with Graves disease two years ago but has not taken any medications for the past six months. Temperature is 39.8°C (103.6°F), blood pressure is 155/65 mm Hg, pulse is 152/min and irregular, and respirations are 26/min. Physical examination shows a confused, diaphoretic woman with a diffusely enlarged, non-tender thyroid gland, bilateral proptosis, and severe fine resting tremor. ECG shows atrial fibrillation with rapid ventricular response. A diagnosis of thyroid storm is made, and the patient is admitted to the intensive care unit.

Arrange the following pharmacologic interventions in the most appropriate chronological order of administration for this patient's comprehensive management, from initial acute stabilization to long-term definitive therapy.

A 48-year-old man comes to the clinic for a routine follow-up examination. Three months ago, he was diagnosed with type 2 diabetes mellitus and started on metformin. He reports that he has been adherent to his medication and has started a structured exercise program. He has no other medical conditions. He does not use tobacco or illicit drugs, and drinks alcohol occasionally. His blood pressure is 126/78 mm Hg, pulse is 76/min, and BMI is 29 kg/m2. Recent laboratory studies show a hemoglobin A1c of 6.8%. His vaccination records indicate that he received all standard childhood vaccines, a tetanus-diphtheria-acellular pertussis (Tdap) booster 3 years ago, a hepatitis B vaccine series in his twenties, and the seasonal influenza vaccine 1 month ago. He has never received a pneumococcal vaccine. Which of the following is the most appropriate recommendation regarding pneumococcal immunization for this patient?

An emergency medical services team transports a 72-year-old male resident of an assisted living facility to the hospital for evaluation of worsening confusion, productive cough, and subjective fevers over the last 72 hours. His medical history includes paroxysmal atrial fibrillation, heart failure with preserved ejection fraction, and type 2 diabetes mellitus. His prescribed medications are amiodarone, apixaban, empagliflozin, and metformin. He has no known drug allergies and has not required antimicrobial therapy or hospitalization in the past twelve months.

Upon assessment in the emergency department, his temperature is 38.8°C (101.8°F), blood pressure is 112/68 mm Hg, heart rate is 108/min and irregularly irregular, respiratory rate is 24/min, and oxygen saturation is 92% on 2 L/min of supplemental oxygen via nasal cannula. Auscultation of the lungs reveals bronchial breath sounds and crackles over the left lower lung zones.

Pertinent laboratory values include:
Leukocyte count: 15,500/mm³
Serum creatinine: 1.1 mg/dL
Blood urea nitrogen: 28 mg/dL

A chest radiograph confirms a left lower lobe consolidation. A 12-lead electrocardiogram demonstrates atrial fibrillation with a ventricular rate of 105/min and a corrected QT (QTc) interval of 535 msec. The patient is admitted to the general medical ward for the treatment of community-acquired pneumonia. Which of the following is the most appropriate empiric antimicrobial regimen for this patient?

A 34-year-old man is evaluated in the psychiatric clinic for a routine follow-up visit. He has a 10-year history of schizophrenia. Over the past several years, he has continued to experience frequent auditory hallucinations, profound negative symptoms, and persecutory delusions despite documented medication adherence and adequate therapeutic trials of olanzapine, risperidone, and haloperidol. The physician and patient agree to initiate clozapine therapy.

As part of this patient's long-term management, which of the following laboratory parameters require routine ongoing monitoring? (Select all that apply)

A $68$-year-old woman is evaluated in the emergency department for a $3$-day history of fever, chills, right flank pain, and dysuria. Her medical history is significant for type $2$ diabetes mellitus, essential hypertension, and stage $3\text{a}$ chronic kidney disease with a baseline serum creatinine of $1.4 \text{ mg/dL}$. Her daily home medications include metformin, lisinopril, empagliflozin, and atorvastatin.

Vital signs show a temperature of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure of $92/58 \text{ mmHg}$, pulse of $112/\text{min}$, and respiratory rate of $18/\text{min}$. Physical examination reveals dry mucous membranes and marked right costovertebral angle tenderness.

Laboratory studies show:
Leukocyte count: $16,500/\text{mm}^3$
Serum sodium: $138 \text{ mEq/L}$
Serum potassium: $4.8 \text{ mEq/L}$
Serum creatinine: $2.4 \text{ mg/dL}$
Blood urea nitrogen: $42 \text{ mg/dL}$
Serum bicarbonate: $18 \text{ mEq/L}$
Urinalysis: positive for nitrites, leukocyte esterase, and $>50 \text{ WBCs/hpf}$.

The patient receives a $1\text{-L}$ bolus of intravenous lactated Ringer solution. Blood and urine cultures are obtained.

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

An ambulatory care physician conducts a telehealth consultation with a 65-year-old female patient reporting a 48-hour history of spontaneous epistaxis and multiple large bruises on her extremities. Her medical history is notable for nonvalvular atrial fibrillation. To prevent thromboembolism, she has taken rivaroxaban daily for three years without hemorrhagic events. Four days prior to this consultation, she visited an urgent care center for acute bronchitis and was given a prescription for a 10-day course of clarithromycin. The patient denies experiencing headaches, visual disturbances, motor weakness, or dark stools. Vital signs are within normal limits. Which of the following is the most appropriate next step in the patient's management?

A 35-year-old woman comes to the clinic for a routine health maintenance visit. She was diagnosed with severe Crohn disease 4 years ago, which is currently well-controlled on a regimen of infliximab and azathioprine. She feels well and has no acute complaints. She has a 10-pack-year smoking history but quit 2 years ago. Her most recent cervical cancer screening was normal 1 year ago, following three consecutive normal annual screenings. She received a tetanus, diphtheria, and acellular pertussis (Tdap) booster 4 years ago and the inactivated influenza vaccine 2 months ago. She has never received a pneumococcal vaccine. Which of the following is the most appropriate next step in preventive care for this patient?

A $52$-year-old man is hospitalized for a $5$-day history of right-sided pleuritic chest pain, nonproductive cough, and subjective fevers. Eighteen months ago, he underwent bilateral lung transplantation for idiopathic pulmonary fibrosis. His daily medications include tacrolimus, mycophenolate mofetil, prednisone, and pantoprazole. He is also receiving therapeutic subcutaneous enoxaparin for a provoked deep vein thrombosis diagnosed $3$ weeks ago.

Vital signs show a temperature of $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), heart rate of $98/\text{min}$, blood pressure of $135/85\text{ mm Hg}$, and respiratory rate of $18/\text{min}$. Oxygen saturation is $96\%$ on room air.

Laboratory studies are as follows:
Leukocyte count: $6,500/\text{mm}^3$
Platelet count: $180,000/\text{mm}^3$
Serum creatinine: $1.1\text{ mg/dL}$
Aspartate aminotransferase (AST): $24\text{ U/L}$
Alanine aminotransferase (ALT): $28\text{ U/L}$

A chest computed tomography (CT) scan reveals a dense $3\text{-cm}$ consolidation in the right upper lobe surrounded by a halo of ground-glass attenuation. Serum galactomannan assay is markedly elevated. The patient is diagnosed with invasive pulmonary aspergillosis, and the decision is made to initiate intravenous voriconazole.

Which of the following is the most appropriate concurrent pharmacologic intervention?