Patient Management

A physician is evaluating several patients in an outpatient clinic. Each patient presents with a different level of readiness to change their health behaviors. Match each patient's clinical scenario and statement to the most appropriate physician counseling response based on the Transtheoretical Model of Change.

A 67-year-old woman comes to the clinic for a routine health maintenance examination. She has no acute symptoms and feels well. Her medical history is notable for hypertension, type 2 diabetes mellitus, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy performed at age 52. A review of her surgical pathology report from that time confirms the procedure was a treatment for persistent cervical intraepithelial neoplasia grade 3 (CIN 3). She has no history of invasive cervical cancer. Her mother was diagnosed with ovarian cancer at age 65, and her father died of a myocardial infarction at age 70. The patient smoked 1.5 packs of cigarettes daily from age 20 to age 50 (a 45 pack-year history) but quit completely 17 years ago. She occasionally drinks wine.

Recent screening history is as follows:
- Screening mammogram 6 months ago: normal
- Screening colonoscopy 6 years ago: normal, no polyps
- Vaginal cuff cytology and HPV co-testing 6 years ago: negative
- Dual-energy x-ray absorptiometry (DEXA) 1 year ago: T-score of -1.5 at the lumbar spine

Her most recent comprehensive metabolic panel and lipid panel, obtained 6 months ago, were within normal limits. Her vaccinations are up to date.

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

A 52-year-old woman comes to the clinic for a routine health maintenance evaluation. She has a history of severe seropositive rheumatoid arthritis, which is currently well-controlled on a regimen of methotrexate and infliximab. She has a 25 pack-year smoking history and currently smokes one pack of cigarettes daily.

Review of her preventive health records reveals the following:
- Colonoscopy at age 46: no polyps or mucosal abnormalities
- Screening mammography at age 51: Breast Imaging Reporting and Data System (BI-RADS) category 1 (negative)
- Cervical cytology with human papillomavirus (HPV) cotesting at age 51: negative
- Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine: administered 2 years ago
- Inactivated influenza vaccine: administered 1 month ago

The patient has never received a pneumococcal, zoster, or measles-mumps-rubella (MMR) vaccine in adulthood, though her childhood records indicate she completed the primary pediatric series for all standard vaccines. Her body mass index is 26 kg/m².

Which of the following preventive interventions are indicated for this patient at today's visit? (Select all that apply)

Evaluate the following end-of-life patient presentations and pair them with the optimal pharmacological intervention.

A 68-year-old female patient presents to a new primary care physician for a wellness visit after relocating to another state. She reports feeling completely well and has not sought medical care for the past 14 years. Her only daily medication is hydrochlorothiazide for hypertension. The patient went through menopause at age 52 and denies any postmenopausal bleeding. She has been in a monogamous marriage for over four decades. A thorough review of her limited medical records reveals that her last pelvic examination and Papanicolaou test were performed when she was 54 years old. That test was normal, and she has never had an abnormal cervical cancer screening result or a history of sexually transmitted infections. The patient asks if she needs any gynecologic tests today.

Which of the following is the most appropriate next step in management regarding cervical cancer screening?

A 62-year-old woman comes to the clinic for a 1-week follow-up visit after being hospitalized for a non-ST-elevation myocardial infarction. During her hospitalization, she underwent percutaneous coronary intervention with the placement of a drug-eluting stent. Her discharge medications include aspirin, ticagrelor, atorvastatin, metoprolol, and lisinopril. During the current visit, the patient expresses frustration with her new daily regimen. She places a bottle of red yeast rice extract and a bottle of ginkgo biloba on the examination table and says, "I am tired of putting synthetic chemicals into my body. A friend told me these natural supplements work just as well without the toxic side effects. I stopped taking the atorvastatin and ticagrelor three days ago and started taking these instead." Which of the following is the most appropriate initial response by the physician?

During routine outpatient encounters, physicians must tailor their counseling strategies to the patient's current readiness to change. Match each patient statement regarding behavioral change (left) with the most appropriate, stage-matched physician counseling strategy (right) based on the transtheoretical model of change.

Review the following four clinical profiles of patients presenting for ambulatory examinations. Match each patient's clinical profile with the most appropriate, guideline-concordant next step in preventive management.

A 74-year-old man with advanced frontotemporal dementia and progressive dysphagia is admitted to the medical intensive care unit for septic shock secondary to aspiration pneumonia. He is intubated, unarousable, and lacks medical decision-making capacity. A thorough review of his medical record reveals no documented advance directive, living will, or designated healthcare proxy. The clinical team concludes that continuing aggressive life-prolonging measures may not align with the patient's prior values and seeks to initiate an urgent goals-of-care discussion regarding palliative extubation. Arrange the following individuals in the standard legal hierarchy of priority to act as the patient's default surrogate healthcare decision-maker, from highest priority (first) to lowest priority (last).

A 52-year-old woman with advanced cervical cancer complicated by bilateral hydronephrosis is admitted to the hospital with intractable pelvic pain and rapidly progressing altered mental status. Over the past three days, her pain became increasingly difficult to control at home, prompting her outpatient physician to double her dose of sustained-release oral morphine. On evaluation, the patient is agitated, picking at her bedsheets, and disoriented to time and place. She exhibits sudden, involuntary jerking movements of her upper and lower extremities. When the physician gently palpates her arm to check her pulse, she screams, complaining that her skin "feels like it is on fire." Vital signs are temperature 37.2°C (99.0°F), pulse 110/min, respirations 16/min, and blood pressure 138/85 mm Hg. Oxygen saturation is 96% on room air. Neurologic examination reveals diffuse hyperalgesia, hyperreflexia, and multifocal myoclonus. Laboratory studies show a serum creatinine level of 3.4 mg/dL (baseline 1.1 mg/dL one month ago). Which of the following is the most appropriate next step in the management of this patient?

A 75-year-old man with a history of heart failure and osteoarthritis presents to the emergency department with a 3-day history of fever, productive cough, and acute confusion. Vital signs show a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure of $85/50$ mm Hg, heart rate of $115$/min, and respiratory rate of $32$/min. Laboratory studies reveal a blood urea nitrogen (BUN) of $40$ mg/dL. He is diagnosed with severe community-acquired pneumonia. Over the subsequent weeks, his infection is successfully treated, but he experiences profound deconditioning. Prior to admission, he was entirely independent with his activities of daily living. Currently, he requires moderate assistance to transfer from a bed to a chair and tolerates a maximum of $45$ minutes of physical therapy daily. His long-term goal is to return to his baseline level of independent living in the community.

Arrange the following care settings in the most appropriate chronological sequence for this patient's complete transition of care, from initial emergency department disposition to final community recovery, based on standard risk stratification and functional assessment guidelines.

A 22-year-old woman is brought to the emergency department by ambulance due to the rapid onset of severe breathing difficulty and lightheadedness. She was at a seafood restaurant when her symptoms began approximately 15 minutes ago. On arrival, the patient is lethargic and gasping for air. She exhibits prominent facial and lip swelling, and a diffuse, raised erythematous rash is visible on her trunk and extremities. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 72/40 mm Hg, pulse of 145/min, respirations of 32/min, and oxygen saturation of 84% on room air. Examination reveals profound oropharyngeal edema and audible stridor. Intravenous access is rapidly established. Which of the following are the most appropriate simultaneous initial steps in stabilizing this patient? (Select all that apply)

A 52-year-old man comes to the outpatient clinic for a routine follow-up. Over the past two years, he has noticed that his wedding ring no longer fits and he has had to purchase shoes two sizes larger than his previous size. He also reports new-onset frequent headaches, excessive daytime sweating, and bilateral knee pain. Six months ago, he was diagnosed with type 2 diabetes mellitus, which has been difficult to control despite maximum doses of metformin. His blood pressure is 158/96 mmHg, pulse is 76/min, and respirations are 14/min. Physical examination reveals coarse facial features, prominent supraorbital ridges, a large fleshy nose, and an enlarged tongue. His hands and feet are markedly enlarged with doughy skin. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

An adult male, aged 62, presents to the acute care clinic triage area reporting five days of worsening chest tightness, profound weakness, and shortness of breath. His medical history is notable for recently completing radiation therapy for non-small cell lung cancer. While providing his history, he abruptly loses consciousness and slumps to the floor. Clinic staff rapidly transport him to the resuscitation bay. Vital signs demonstrate a pulse of 132/min, blood pressure of 65/40 mmHg, and respirations of 28/min. Physical examination reveals prominently distended external jugular veins, clear lung fields bilaterally, and significantly distant, muffled cardiac tones. His extremities are cool and diaphoretic. Which of the following is the most appropriate immediate step in the management of this patient?

Emergency medical responders arrive at the resuscitation bay with a 28-year-old male who was found unconscious by his flatmate. Several empty pill bottles, including amitriptyline and diphenhydramine, were recovered from his bedroom. Initial vital signs show a blood pressure of 82/48 mm Hg, heart rate of 138/min, respiratory rate of 8/min, and oxygen saturation of 90% on ambient air. The patient makes incomprehensible sounds, does not open his eyes to painful stimuli, and exhibits abnormal flexion in his upper extremities. His skin is notably hot, flushed, and dry, and bilateral pupils measure 7 mm with sluggish reactivity. An immediate 12-lead electrocardiogram reveals sinus tachycardia with a QRS duration of 155 ms and a prominent terminal R wave in lead aVR. Which of the following interventions represent the most critical immediate stabilization steps for this patient? (Select exactly 3 options)

A $34$-year-old woman presents to the clinic with new-onset headaches, palpitations, and severe muscle cramps. Her blood pressure is $172/106$ mmHg. A basic metabolic panel reveals a serum sodium of $144$ mEq/L and a serum potassium of $2.8$ mEq/L. She is not taking any medications and has no family history of early-onset hypertension. The physician suspects an endocrine etiology for her secondary hypertension. Assuming each investigative step confirms the indication for the next and the patient is a candidate for surgical management, arrange the following diagnostic steps in the correct, guideline-directed chronological sequence from initial workup to preoperative planning.

A 48-year-old man presents to the ambulatory care clinic with a 2-day history of right leg swelling and calf pain. He recently returned from a 12-hour international flight. His temperature is 37.1°C (98.8°F), blood pressure is 128/82 mmHg, pulse is 76/min, and respiratory rate is 14/min. Physical examination reveals pitting edema and tenderness in the right lower extremity below the knee. Point-of-care compression ultrasonography demonstrates a noncompressible right popliteal vein. Laboratory testing shows a serum creatinine of 0.9 mg/dL and normal liver function tests. The patient is hemodynamically stable, ambulatory, and has reliable access to outpatient follow-up. Which of the following is the most appropriate initial pharmacologic intervention for this patient?

A 42-year-old man presents to the outpatient clinic reporting chronic diffuse joint pain, increasing fatigue, and excessive sweating over the past year. He mentions that he recently had to purchase larger shoes and his wedding ring can no longer be worn. His medical history includes newly diagnosed type 2 diabetes mellitus and hypertension. Vital signs show a blood pressure of $145/90 \text{ mmHg}$, a heart rate of $78\text{/min}$, and a BMI of $29 \text{ kg/m}^2$. Physical examination reveals coarse facial features, a prominent jaw, macroglossia, and enlarged, doughy hands. Initial laboratory testing reveals an elevated serum insulin-like growth factor 1 (IGF-1) concentration for his age and sex. Which of the following is the most appropriate next step in the diagnostic workup?

A 61-year-old man is evaluated in the outpatient clinic for a persistent ulcer on the plantar aspect of his left first metatarsophalangeal joint, which he first noticed six weeks ago. His medical history is significant for type 2 diabetes mellitus complicated by peripheral neuropathy, as well as stage 3 chronic kidney disease. He reports no fevers, chills, or systemic symptoms. Vital signs are within normal limits. Physical examination reveals a $2 \text{ cm} \times 2 \text{ cm}$ ulcer with raised borders and a granulating, mildly exudative base. Surrounding erythema extends $1 \text{ cm}$ from the ulcer margin. Sensation to a 10-gram monofilament is absent in the bilateral distal lower extremities. During the examination, a sterile, blunt stainless-steel probe is introduced into the ulcer and advances seamlessly until a hard, gritty surface is encountered. Laboratory studies show a leukocyte count of $8,500/\text{mm}^3$ and an erythrocyte sedimentation rate of $82 \text{ mm/h}$. A plain radiograph of the left foot reveals soft tissue swelling but no radiopaque foreign bodies, subcutaneous gas, or distinct cortical destruction. Which of the following is the most appropriate next step in the diagnostic workup?

An 81-year-old woman is evaluated for discharge planning on post-operative day 5 following an open reduction and internal fixation of a left intertrochanteric femur fracture. Her hospitalization was complicated by a brief episode of postoperative delirium, which has now completely resolved. She is currently medically stable, alert, and oriented. Her vital signs are within normal limits, and her surgical incision is clean and intact. Prior to her fall, she lived in a single-story home with her 84-year-old husband and ambulated independently without assistive devices. The physical therapy team reports that she currently requires moderate assistance for bed-to-chair transfers and can ambulate approximately 15 feet with a front-wheeled walker. During therapy sessions, she becomes profoundly exhausted after 45 minutes and is unable to participate in further physical or occupational therapy for the remainder of the day. The patient and her husband express a strong desire for her to eventually return home. Which of the following is the most appropriate care setting transition for this patient at this time?