Patient Management

A 58-year-old woman is evaluated in the intensive care unit for a rapidly declining platelet count. She was admitted 6 days ago for severe pneumonia and started on broad-spectrum antibiotics and prophylactic subcutaneous unfractionated heparin. Her platelet count on admission was $250,000/\mu L$ and is now $55,000/\mu L$. She has no active bleeding, but a lower extremity ultrasound reveals a new deep vein thrombosis in the right femoral vein. The clinical team diagnoses highly probable heparin-induced thrombocytopenia (HIT) with thrombosis. Arrange the following steps regarding the ongoing monitoring and transition of pharmacotherapy for this patient in the most appropriate chronological sequence.

A 72-year-old man with a 6-year history of Parkinson disease is brought to the neurology clinic by his wife due to new-onset visual hallucinations over the past two weeks. He reports seeing unfamiliar people standing in his living room, which is causing him significant distress. His motor symptoms (tremor and bradykinesia) have been well-controlled recently. His current daily medication regimen includes carbidopa-levodopa, pramipexole, amantadine, and trihexyphenidyl. Vital signs are within normal limits. Neurologic examination shows mild resting tremor and rigidity, unchanged from his previous visit. Laboratory studies, including a urinalysis and basic metabolic panel, are unremarkable.

According to the standard step-wise approach for managing Parkinson disease-related psychosis, arrange the following pharmacologic modifications in the correct sequential order (from the first step to the final step).

A 68-year-old man is evaluated in the outpatient clinic for a 1-day history of severe right great toe pain, swelling, and redness. He reports the pain woke him from sleep and is so exquisite that he cannot bear the weight of a bedsheet on his foot. Medical history is notable for hypertension, type 2 diabetes mellitus, and chronic kidney disease stage 3b. One week ago, he was diagnosed with a peptic ulcer associated with Helicobacter pylori and was started on a 14-day eradication regimen. Current medications include lisinopril, amlodipine, clarithromycin, amoxicillin, and omeprazole. Vital signs are temperature 37.3°C (99.1°F), blood pressure 138/82 mmHg, and pulse 88/min. Physical examination shows a swollen, erythematous, and exquisitely tender right first metatarsophalangeal joint. Arthrocentesis is performed, and synovial fluid analysis reveals a leukocyte count of 25,000/mm³ and negatively birefringent, needle-shaped crystals. Gram stain is negative. Laboratory studies show:

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

A 62-year-old man with a 12-year history of type 2 diabetes mellitus and chronic kidney disease is evaluated during a routine follow-up visit. One month ago, his hemoglobin A1c was 8.1% and his estimated glomerular filtration rate (eGFR) was 45 mL/min/1.73 m $^2$. At that time, dapagliflozin was added to his medication regimen, which also includes metformin and lisinopril, to optimize glycemic control and slow the progression of diabetic nephropathy. Today, the patient reports feeling well overall. He denies urinary frequency, dysuria, dizziness, or orthopnea. He mentions having mild, intermittent bilateral knee pain due to osteoarthritis and asks for a medication recommendation. His blood pressure is 126/78 mm Hg and heart rate is 74/min.

Laboratory studies obtained today show:

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

A 45-year-old man is evaluated in the hospital prior to discharge. He was admitted three days ago for acute dyspnea and was found to have a new-onset nonischemic cardiomyopathy with a left ventricular ejection fraction of 20%. He has been treated with intravenous furosemide and is now breathing comfortably on room air. He has no orthopnea, and his volume status is clinically optimized. Medical history is notable for hypertension and an episode of severe lip swelling and airway compromise requiring epinephrine after taking lisinopril two years ago. Current vital signs are blood pressure 118/75 mmHg, heart rate 72/min, and respirations 14/min.

Laboratory results obtained this morning are as follows:

Which of the following pharmacologic interventions are appropriate to initiate prior to discharge? (Select all that apply)

A 71-year-old man presents to the outpatient clinic for a follow-up appointment four weeks following a hospitalization for new-onset atrial fibrillation. While admitted, oral amiodarone was initiated for maintenance of sinus rhythm. The patient reports feeling well with no palpitations, dyspnea, or chest pain. His current medications include amiodarone, lisinopril, and atorvastatin. Today's electrocardiogram demonstrates normal sinus rhythm with a heart rate of 68/min and a QTc interval of 430 ms. The physician counsels the patient on the necessity of longitudinal follow-up to detect potential medication-induced toxicities. Which of the following evaluations are required as part of routine periodic monitoring for this patient's antiarrhythmic therapy? (Select all that apply)

A $29$-year-old woman presents to the clinic for her first prenatal visit. She is currently at $6$ weeks of gestation based on her last menstrual period. The patient has a $4$-year history of Hashimoto thyroiditis and has been well-controlled on levothyroxine $100$ mcg daily for the past two years. She reports no symptoms of fatigue, cold intolerance, constipation, or weight changes. Her most recent serum thyroid-stimulating hormone (TSH) level obtained $3$ months ago was $1.6$ $\mu$ U/mL (reference range: $0.4-4.0$ $\mu$ U/mL). A home pregnancy test was positive one week ago, and a serum human chorionic gonadotropin level drawn yesterday confirms the pregnancy. Vital signs and physical examination today are unremarkable. Which of the following is the most appropriate next step in the monitoring and management of this patient's thyroid disease?

A 32-year-old man is brought to the emergency department by ambulance due to a generalized tonic-clonic seizure. His partner reports that the abnormal movements started 20 minutes ago and have been continuous without any periods of responsiveness. He has no known medical history. Initial vital signs include a blood pressure of 145/85 mm Hg, heart rate of 118/min, and oxygen saturation of 94% on room air. No medications were administered en route. Two large-bore peripheral intravenous lines are immediately established in the resuscitation bay. Arrange the following pharmacologic interventions in the evidence-based sequence for the escalating management of status epilepticus, from initial abortive therapy to the treatment of super-refractory cases.

An internal medicine physician is called to the bedside of a 24-year-old male patient who is receiving care in the critical care unit for diabetic ketoacidosis. The patient was admitted 14 hours prior and has been treated with continuous intravenous fluids, a regular insulin infusion, and an electrolyte protocol. The nursing staff reports that his vital signs are stable, and he is now awake, conversational, and asking for a meal.

The clinical team determines the patient is ready to transition to a subcutaneous insulin regimen. Arrange the following steps for transitioning therapies and monitoring in the most appropriate chronological sequence.

During a routine follow-up visit, a 62-year-old male patient reports a two-week history of bilateral thigh and shoulder pain accompanied by mild weakness. His medical history is significant for a myocardial infarction 6 months prior, and his current daily medication regimen includes aspirin, metoprolol, lisinopril, and atorvastatin 80 mg. Vital signs are within normal limits. On physical examination, there is noticeable tenderness upon palpation of the quadriceps and deltoid muscles bilaterally, and proximal muscle strength is graded at 4/5.

Laboratory studies are obtained and reveal the following:

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

A 68-year-old man is evaluated in the hospital prior to discharge. He was admitted five days ago for acute decompensated heart failure. Echocardiography performed during the admission showed a left ventricular ejection fraction of 30%. His volume status was optimized with intravenous furosemide. He is now clinically stable and transitioned to an oral regimen consisting of furosemide, carvedilol, dapagliflozin, lisinopril, and spironolactone. He has an appointment to be seen in the outpatient clinic in one week. Which of the following laboratory parameters are most critical to measure at his upcoming clinic visit to monitor for potentially life-threatening adverse effects of his updated medication regimen? (Select all that apply)

A 64-year-old man is currently receiving mechanical ventilation in the intensive care unit following a severe traumatic brain injury. On hospital day 5, he develops a new fever of 39.2°C (102.6°F), an increased requirement for fraction of inspired oxygen (FiO2), and thick, purulent endotracheal secretions. A portable chest radiograph reveals a new left lower lobe consolidation. The patient is hemodynamically stable but exhibits signs of systemic inflammation.

Arrange the following steps in the most appropriate chronological sequence for the diagnostic workup, therapeutic management, and subsequent monitoring of this patient's suspected ventilator-associated pneumonia (VAP).

A 42-year-old woman presents to the emergency department with a 2-day history of high fever, chills, and severe sore throat. She was diagnosed with hyperthyroidism due to Graves' disease 4 weeks ago and was started on methimazole and propranolol. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $110/70$ mm Hg, heart rate is $112$/min, and respiratory rate is $18$/min. Physical examination reveals marked pharyngeal erythema with tonsillar exudates but no neck asymmetry or airway compromise. Laboratory studies show:

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

A 22-year-old woman comes to the dermatology clinic for the management of severe nodulocystic acne. Over the past six months, she has been treated with oral doxycycline and topical benzoyl peroxide, but her condition has worsened. She has deep, painful cystic lesions on her face, back, and chest that are beginning to scar. The physician plans to initiate oral isotretinoin. She has no other medical conditions. Which of the following are essential components of this patient's treatment and monitoring plan? (Select all that apply)

A 58-year-old woman is evaluated in the hospital prior to being transferred from the intensive care unit to the general medical ward. She was admitted 6 days ago for a severe exacerbation of chronic obstructive pulmonary disease. Her treatment during hospitalization has included intravenous methylprednisolone, nebulized bronchodilators, and prophylactic subcutaneous unfractionated heparin. Her respiratory status has significantly improved.

Serial laboratory studies reveal the following platelet counts:

On physical examination today, her vital signs are within normal limits. A new, demarcated, erythematous, and exquisitely tender necrotic skin lesion is noted at a recent heparin injection site on her anterior abdomen. There is no mucosal bleeding or petechiae.

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

During a routine health maintenance examination, a physician evaluates a patient with poorly controlled type 2 diabetes mellitus and new-onset eruptive xanthomas on the extensor surfaces. Fasting laboratory results reveal a serum triglyceride concentration of $1,340 \text{ mg/dL}$. The patient is currently managed with metformin monotherapy and lacks any history of atherosclerotic cardiovascular disease.

Please arrange the following clinical actions in the correct chronological sequence for the management and monitoring of this patient's condition over time.

Evaluate the following complex end-of-life patient presentations and pair each with its most appropriate, symptom-specific intervention.

A 68-year-old retired architect is brought to the emergency department by her husband after a transient loss of consciousness. She was sitting in a chair reading when she suddenly "blacked out." Her husband witnessed the event and reports she was unresponsive for approximately 20 seconds. She had no preceding palpitations, chest pain, diaphoresis, or nausea. There was no limb jerking or urinary incontinence, and she returned to her baseline mental status immediately upon awakening. Her medical history includes hypertension and hyperlipidemia. Blood pressure is 138/82 mmHg, heart rate is 64/min, and respiratory rate is 14/min. Orthostatic vital signs show no significant changes. Physical examination reveals clear lungs and a 2/6 late-peaking systolic murmur at the right upper sternal border. Neurologic examination is nonfocal. An electrocardiogram demonstrates normal sinus rhythm with left axis deviation and a new right bundle branch block (bifascicular block). Basic metabolic panel and complete blood count are within normal limits. Which of the following diagnostic studies are indicated as the most appropriate concurrent initial steps in this patient's evaluation? (Select exactly 2)

A 42-year-old woman is evaluated in the surgical intensive care unit on postoperative day 3 following an uncomplicated laparoscopic Roux-en-Y gastric bypass for severe obesity. Over the past 2 hours, she has developed severe, unremitting epigastric pain, severe restlessness, and shortness of breath. Her temperature is 38.8°C (101.8°F), blood pressure is 82/48 mm Hg, heart rate is 135/min, and respiratory rate is 26/min. Pulse oximetry shows 92% on room air. The patient appears diaphoretic, anxious, and acutely ill. Abdominal examination reveals diffuse tenderness, marked involuntary guarding, and rebound tenderness predominantly in the epigastrium. Bowel sounds are absent. Urine output has been 10 mL over the last 2 hours. Laboratory studies show a leukocyte count of 19,000/mm³ with 15% band forms and a serum lactate level of 4.2 mmol/L. She is given a rapid intravenous infusion of 2 L of isotonic crystalloid, after which her blood pressure is 86/52 mm Hg. Which of the following is the most appropriate next step in management?

A 54-year-old woman with severe, seropositive rheumatoid arthritis is evaluated in the rheumatology clinic. She continues to experience active synovitis in multiple metacarpophalangeal and proximal interphalangeal joints despite a 6-month trial of optimized methotrexate and a subsequent 4-month trial of etanercept. The physician decides to initiate intravenous tocilizumab. Her medical history is otherwise unremarkable. Baseline screening for latent tuberculosis and viral hepatitis is negative. Which of the following laboratory evaluations are required as part of the specific baseline and ongoing monitoring for this pharmacotherapy? (Select all that apply)