Patient Management

A primary care physician is evaluating a 71-year-old female during an annual wellness examination. The patient's past medical history is significant for postmenopausal osteoporosis. She was diagnosed 5 years ago after a screening dual-energy x-ray absorptiometry (DEXA) scan showed a femoral neck T-score of -2.8. Following the diagnosis, she began therapy with oral risedronate, which she has taken consistently without any gastrointestinal side effects. She has no history of clinical or radiographic fractures. A DEXA scan completed 3 days ago reports a current femoral neck T-score of -2.1. Her daily routine includes walking two miles, and she takes over-the-counter cholecalciferol and calcium carbonate. Renal function and serum calcium are within normal limits. She inquires about her future medication plan. Which of the following is the most appropriate next step in management?

A 58-year-old woman is brought to the emergency department by her husband due to a 3-day history of increasing confusion, sluggishness, and tremors. Her husband reports that she has been sleeping more than usual and has had difficulty holding a glass of water without spilling it. Her medical history is significant for bipolar I disorder, for which she has been stable on lithium carbonate 900 mg daily for the past 5 years. She also has osteoarthritis and began taking naproxen 500 mg twice daily two weeks ago for worsening knee pain.

On physical examination, temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, pulse is 88/min, and respirations are 14/min. She appears lethargic but is easily arousable. Neurologic examination reveals a prominent coarse, irregular tremor in her upper extremities bilaterally, as well as hyperreflexia in all four extremities. No nuchal rigidity is noted.

Serial laboratory studies are shown below:

An electrocardiogram shows normal sinus rhythm with no ST-segment or T-wave abnormalities.

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

A 68-year-old man comes to the clinic for a 1-week follow-up after an adjustment to his heart failure medications. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 25%. One week ago, spironolactone 25 mg daily was added to his guideline-directed medical therapy regimen to further reduce morbidity and mortality. He is also taking sacubitril-valsartan, carvedilol, and dapagliflozin. The patient reports feeling well and has no shortness of breath, orthopnea, or lower extremity edema. His blood pressure is 114/72 mm Hg, and his pulse is 62/min. Physical examination reveals clear lungs and no jugular venous distention. Laboratory studies obtained today, compared to his baseline from one week ago, are shown in the table below:

Which of the following is the most appropriate next step in the monitoring and treatment evaluation of this patient?

A 52-year-old man visits the clinic due to sudden, severe pain and swelling in his right big toe that began overnight. He is unable to bear weight on the affected foot. His medical history is significant for a deceased-donor renal allograft performed three years ago for end-stage renal disease secondary to hypertensive nephrosclerosis. His current medications include tacrolimus, mycophenolate mofetil, and low-dose prednisone. Vital signs are within normal limits. Physical examination reveals a swollen, erythematous, and exquisitely tender right first metatarsophalangeal joint. Joint aspiration is performed, and synovial fluid analysis reveals negatively birefringent, needle-shaped crystals under polarized light microscopy. His serum creatinine today is 1.6 mg/dL, which is unchanged from his baseline over the past year. Which of the following is the most appropriate pharmacologic intervention for this patient's acute joint condition?

A 27-year-old woman, gravida 1 para 0, presents to the emergency department with two days of mild, intermittent left lower quadrant abdominal pain and light vaginal spotting. Her last menstrual period was six weeks ago. She has no significant past medical history and takes only prenatal vitamins. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 118/74 mm Hg, heart rate of 82/min, and respiratory rate of 14/min. Physical examination reveals mild left adnexal tenderness on palpation but no cervical motion tenderness or palpable masses. The cervical os is closed, and there is no active bleeding in the vaginal vault. A serum quantitative $\beta$-human chorionic gonadotropin ($\beta$-hCG) level is $950$ mIU/mL. Transvaginal ultrasonography demonstrates a thickened endometrial stripe of 12 mm without a visible intrauterine gestational sac, no adnexal masses, and no free pelvic fluid. Which of the following is the most appropriate next step in evaluating this patient's condition?

Emergency medical services transport a 24-year-old male with a known history of severe persistent asthma to the acute care bay. According to his roommate, the patient experienced progressively worsening shortness of breath over the past 24 hours and had been using his albuterol inhaler continuously with no clinical improvement. Upon evaluation, the patient is obtunded, profoundly diaphoretic, and cannot answer questions or follow commands. His vital signs show a temperature of 37.1°C, heart rate of 145/min, blood pressure of 112/68 mmHg, and a decreasing respiratory rate of 8/min with shallow excursions. Pulse oximetry reads 85% despite high-flow supplemental oxygen via a non-rebreather mask. Auscultation of the lungs reveals a 'silent chest' with markedly diminished air movement and no audible wheezing bilaterally. Which of the following is the most appropriate immediate next step in the stabilization of this patient?

An emergency medical services team brings a 64-year-old man to the resuscitation bay due to sudden-onset, agonizing chest pain that he describes as 'ripping' and radiating directly to his shoulder blades. The pain started abruptly one hour ago while he was carrying groceries. He has a known history of tobacco use and medication nonadherence for hypertension. The patient is visibly distressed, sweating profusely, and unable to find a comfortable position on the stretcher.

Vital signs:
Temperature: 37.1°C (98.8°F)
Blood pressure: 220/120 mm Hg in the right arm, 175/90 mm Hg in the left arm
Heart rate: 118/min
Respiratory rate: 24/min
Oxygen saturation: 97% on room air

An electrocardiogram demonstrates sinus tachycardia with left ventricular hypertrophy but no ST-segment or T-wave abnormalities. A stat portable chest radiograph shows a widened mediastinum.

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

A $71$-year-old female presents to the cardiology clinic for an urgent consultation regarding worsening shortness of breath and ankle swelling over the past $6$ weeks. She reports needing three pillows to sleep at night and becomes breathless after walking just one block. Her past medical history is notable for seropositive rheumatoid arthritis, type 2 diabetes mellitus, essential hypertension, and stage 4 chronic kidney disease. Her medication regimen includes oral methotrexate, subcutaneous adalimumab, metformin, sitagliptin, and lisinopril.

Vital signs show a blood pressure of $134/82 \text{ mmHg}$ and a heart rate of $88\text{ /min}$. Physical examination reveals distended jugular veins, crackles in the lower third of both lung fields, and bilateral $2+$ pitting edema up to the mid-calves.

A transthoracic echocardiogram reveals global hypokinesis with an estimated left ventricular ejection fraction of $25\%$.

Current laboratory values:
Serum potassium: $4.6 \text{ mEq/L}$
Serum creatinine: $2.5 \text{ mg/dL}$ (estimated GFR: $22 \text{ mL/min/}1.73 \text{ m}^2$; baseline $3$ months ago: $2.4 \text{ mg/dL}$)
Hemoglobin A1c: $7.2\%$

Which of the following sets of modifications to this patient's current medications is most appropriate?

A $34$-year-old man arrives at the trauma bay via helicopter emergency medical services after a high-speed motorcycle collision. He is agitated, pale, and diaphoretic. Vital signs show a blood pressure of $74/40$ mm Hg, a heart rate of $145$/min, and a respiratory rate of $36$/min. His oxygen saturation is $86\%$ despite receiving high-flow oxygen via a nonrebreather mask. Clinical evaluation demonstrates rightward tracheal deviation and absent breath sounds over the left hemithorax, which is hyperresonant to percussion. An anteroposterior compression force on the iliac crests reveals marked pelvic instability. Peripheral intravenous access has just been established. Which of the following simultaneous interventions are the most appropriate immediate next steps in management? (Select all that apply)

A 38-year-old man is admitted to the hospital for intravenous antibiotic therapy for right lower extremity cellulitis. His past medical history is significant for treatment-resistant schizophrenia, which has been well-controlled for three years on a stable dose of clozapine (500 mg daily). He smokes two packs of cigarettes per day. Because the hospital is a smoke-free facility, he is prescribed a 21-mg nicotine transdermal patch upon admission to prevent withdrawal symptoms. His admission laboratory studies, including a serum creatinine of 0.8 mg/dL and normal liver enzymes, are unremarkable. He is started on intravenous daptomycin. On hospital day 4, the patient experiences a first-time generalized tonic-clonic seizure. Vital signs immediately following the event are temperature 37.0°C (98.6°F), blood pressure 132/82 mmHg, heart rate 94/min, and respiratory rate 16/min. Neurologic examination demonstrates post-ictal confusion but no focal deficits.

Which of the following medication management strategies upon admission would have most likely prevented this patient's new-onset neurologic complication?

During multidisciplinary rounds, the care team is planning the next steps for a patient who recently underwent an emergent colectomy for perforated diverticulitis. The patient, a retired teacher, has been hospitalized for two weeks. Acute infectious processes have resolved, and intravenous antibiotics were discontinued yesterday. Vital signs are currently within normal limits.

The physical therapy team notes that the patient experiences significant fatigue, tolerating only 40 minutes of low-intensity mobilization exercises before needing to rest for the remainder of the day. Prior to admission, the patient lived independently with a spouse. Currently, the patient requires moderate physical assistance for bed-to-chair transfers and is unable to safely ambulate. Additionally, the patient has a newly formed stoma; the spouse is eager to assist but has not yet demonstrated competency in ostomy appliance changes despite repetitive nursing instruction.

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

A 68-year-old man is hospitalized for a severe exacerbation of chronic obstructive pulmonary disease and newly diagnosed heart failure with preserved ejection fraction. He has stabilized after 4 days of intravenous diuresis and systemic corticosteroids. The medical team is preparing for his transition out of the acute care hospital. He lives with his daughter, who works during the day. He requires new supplemental oxygen and close monitoring of his fluid status. To minimize the risk of readmission and ensure a safe transition of care, arrange the following discharge planning steps in the most appropriate chronological sequence.

A 52-year-old man is brought to the emergency department by paramedics after being found unresponsive at home. His wife reports that he had been vomiting large amounts of bright red blood for the past hour. The patient has a history of alcohol use disorder and cirrhosis. On arrival, he is obtunded, making gurgling respiratory sounds, and has blood pooling in his oropharynx. Vital signs are temperature 36.5°C (97.7°F), blood pressure 70/40 mmHg, pulse 142/min, and respiratory rate 28/min. Arrange the following management steps in the most appropriate sequential order of priority for this patient's initial stabilization.

Paramedics rush a 42-year-old man into the resuscitation bay after extricating him from a burning residential garage. En route, the patient was agitated but spontaneously breathing. His wife, who escaped unharmed, reports that he has a history of type 2 diabetes mellitus but is otherwise healthy. Upon arrival, he remains awake but is visibly distressed and clutching his neck. He communicates with a hoarse voice and repeatedly coughs up dark, carbonaceous sputum. Physical examination reveals soot in the posterior oropharynx, singed nasal vibrissae, and partial-thickness burns over the anterior neck and chest. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 118/74 mm Hg, heart rate of 115/min, and respiratory rate of 28/min. Pulse oximetry displays 99% on room air. Auscultation of the neck demonstrates audible inspiratory stridor. Which of the following is the most appropriate next step in management?

A $36$-year-old man is brought to the burn center after being trapped in a structural fire. He sustained deep partial-thickness and full-thickness thermal burns involving the entire anterior trunk, posterior trunk, and circumferentially around his left upper extremity and both lower extremities. The total body surface area burned is estimated at $60\%$. He was intubated in the field for inhalation injury and is currently receiving aggressive intravenous lactated Ringer resuscitation. Vital signs are temperature $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), heart rate $132$/min, and blood pressure $88/55\text{ mmHg}$. Mechanical ventilation settings are volume control, tidal volume $450\text{ mL}$, respiratory rate $18$/min, $\text{FiO}_2$ $0.80$, and positive end-expiratory pressure (PEEP) $5\text{ cm H}_2\text{O}$. Over the last hour, the ventilator has alarmed continuously for high peak airway pressures, which have risen from $25$ to $55\text{ cm H}_2\text{O}$. His oxygen saturation has declined from $98\%$ to $86\%$. Breath sounds are present but diminished bilaterally. The left hand is cool to the touch, and radial and ulnar pulses are no longer detectable by handheld Doppler. Which of the following are the most appropriate immediate interventions? (Select all that apply)

Match each patient statement regarding lifestyle modification to the most appropriate stage-matched physician counseling strategy based on the Transtheoretical Model of Change.

Match the following ambulatory clinic patients, detailing their demographic and clinical risk profiles, to the single most appropriate evidence-based screening or preventive intervention according to current clinical guidelines.

Review the following patient presentations evaluated in the emergency department. Match each clinical scenario with the most appropriate initial disposition or care setting transition based on their risk stratification and clinical needs.

Evaluate the clinical status, functional capacity, and ongoing medical needs of each patient described below. Match each clinical vignette to the most appropriate post-acute disposition or care setting based on standard utilization criteria.

An 81-year-old male with metastatic prostate cancer is evaluated on the oncology unit for acute confusion, severe agitation, and sudden jerking movements of his extremities. The patient was admitted earlier today for worsening bone pain. His home medications include extended-release morphine 60 mg twice daily and immediate-release morphine 15 mg every 4 hours as needed. According to his wife, he has been taking the as-needed morphine around the clock for the past week. He has a history of chronic kidney disease with a baseline serum creatinine of 1.5 mg/dL. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 135/85 mmHg, pulse of 92/min, and respirations of 16/min. Physical examination reveals a restless, disoriented patient exhibiting frequent, involuntary, shock-like muscle contractions throughout all four limbs. Recent laboratory studies demonstrate a serum creatinine level of 3.6 mg/dL. Which of the following is the most appropriate next step in the management of this patient?