Patient Management

A 42-year-old man is evaluated for discharge planning. Eight weeks ago, he was involved in a high-speed motorcycle collision resulting in a T6 spinal cord transection and complete paraplegia. During his initial prolonged intensive care stay, his course was complicated by a severe stage 4 sacral pressure injury. Ten days ago, he underwent surgical debridement and closure of the ulcer with a gluteal musculocutaneous flap.

His postoperative course has been uncomplicated. The surgical drains were removed yesterday, and the incision is clean, dry, and intact. He is hemodynamically stable, afebrile, and his medications have been transitioned from intravenous to oral routes.

On physical examination, upper extremity strength is 5/5 bilaterally, but he has no sensory or motor function below the T6 level. Per the plastic surgery protocol, he must remain on strict bed rest in prone or alternating lateral decubitus positions for the next 4 weeks to ensure flap viability. He requires assistance from two staff members to turn every 2 hours and must avoid any sitting, shearing forces, or supine positioning. Physical and occupational therapy note that due to these severe positional restrictions, he can currently tolerate a maximum of 45 minutes of recumbent upper-body therapeutic exercise daily. Prior to his injury, he lived alone in a second-floor walk-up apartment.

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

A 60-year-old man with metastatic pancreatic cancer is hospitalized for management of intractable abdominal pain and jaundice. He has a biliary stent placement scheduled for the next day. However, during morning rounds, the patient states that he no longer wants the procedure or any further medical interventions, including his current intravenous antibiotics for ascending cholangitis. He clearly expresses that he understands the risks of stopping treatment, including overwhelming sepsis and imminent death. He states, "I am exhausted and ready to let nature take its course." The patient's adult daughter, who is designated as his healthcare proxy in his advance directive, insists that the medical team proceed with the stent placement and antibiotics, arguing that the patient's pain medications are clouding his judgment. The patient is alert, oriented to person, place, time, and situation, and can clearly articulate the reasoning behind his decision. Which of the following is the most appropriate next step in management?

Match each complex end-of-life clinical scenario with the most appropriate ethical principle or legal determination governing its management.

A psychiatrist is evaluating several patients in the psychiatric emergency department and outpatient clinic to determine the appropriate level of care. Match each patient's clinical presentation and psychosocial status with the most appropriate behavioral health disposition.

During a busy afternoon in an outpatient internal medicine clinic, a physician encounters four patients who report non-adherence to their prescribed medical therapies for various reasons. Match each patient's statement regarding their specific barrier to adherence with the most appropriate, targeted physician counseling response.

During an interdisciplinary family meeting in the intensive care unit regarding a transition to comfort measures, the attending physician navigates a highly charged emotional environment. To foster therapeutic alignment and respond to emotional cues effectively, the physician employs the NURSE framework. Match each physician statement used during the encounter to the specific empathetic communication technique it best represents.

A 48-year-old woman is newly diagnosed with moderate, seropositive rheumatoid arthritis. Her physician decides to initiate disease-modifying therapy with oral methotrexate along with daily folic acid supplementation. Her past medical history is otherwise unremarkable, and baseline laboratory investigations are within normal limits. Which of the following parameters are essential to monitor routinely to detect common adverse effects of this pharmacological therapy? (Select all that apply)

A hospitalist is planning the transition of care for an 81-year-old female patient on hospital day 9. She was initially admitted to the intensive care unit for septic shock secondary to acute pyelonephritis and required vasopressor support for 48 hours. She has been on the general medical floor for the past 5 days and is now hemodynamically stable. Intravenous antibiotics have been transitioned to oral therapy. Her serum creatinine has improved from a peak of $2.8 \text{ mg/dL}$ to $1.3 \text{ mg/dL}$ (baseline $1.0 \text{ mg/dL}$). Her white blood cell count is $9,500/\mu\text{L}$.

Prior to her illness, the patient lived alone in an apartment and managed her own instrumental activities of daily living. Currently, she is alert, oriented, and cognitively intact. However, she exhibits profound generalized weakness. Physical and occupational therapy evaluations note that she requires moderate assistance to transfer from bed to chair and can ambulate only 15 feet with a wheeled walker. She actively participates in therapy but becomes severely fatigued after 45 to 60 minutes of total daily exertion. She requires assistance with bathing and dressing. Her son lives nearby but is unable to provide daytime care.

Which of the following is the most appropriate care setting for this patient's disposition?

A primary care physician is managing a full schedule of adult patients presenting for routine health evaluations. Assign the single most appropriate, guideline-based preventive screening intervention to each patient based on their distinct demographic and risk profile.

Evaluate the following patient presentations from an ambulatory primary care setting. Map each patient's demographic and clinical history to the single most appropriate, evidence-based preventive care intervention required at their current visit.

A 58-year-old woman with metastatic ovarian cancer is evaluated during a home hospice visit for a 4-day history of absent bowel movements and worsening lower abdominal discomfort. She has been taking escalating doses of oral morphine for severe pelvic pain over the past two weeks. Arrange the following steps in the correct chronological sequence for the evaluation and stepwise escalation of management for this patient's suspected opioid-induced constipation.

For each clinical scenario below, select the most appropriate guideline-concordant preventive screening intervention. Assume patients are asymptomatic and up to date with any age-appropriate interventions not explicitly addressed.

A 40-year-old man presents to the outpatient clinic for a routine health maintenance evaluation. He has no significant past medical history and takes no medications. He has never smoked and consumes alcohol occasionally. He has no history of injection drug use or prior blood transfusions. A review of his records shows that his last lipid panel and HIV screening test were performed 5 years ago and were normal. He has never been screened for hepatitis C virus (HCV) infection. Vital signs are normal. Physical examination is unremarkable, with no scleral icterus or hepatomegaly. Which of the following is the most appropriate recommendation regarding HCV screening for this patient?

A 62-year-old man with New York Heart Association class II heart failure with reduced ejection fraction is evaluated in the clinic. He is currently treated with lisinopril, metoprolol succinate, and spironolactone. His symptoms have persisted despite maximal tolerated doses of his current regimen. The physician plans to transition the patient from lisinopril to sacubitril-valsartan. His current blood pressure is 118/75 mm Hg, and his heart rate is 68/min. Laboratory studies show a serum potassium of 4.3 mEq/L and a serum creatinine of 1.1 mg/dL. Which of the following are required steps for appropriate treatment adaptation and ongoing monitoring in this patient? (Select all that apply)

An 82-year-old man with a history of New York Heart Association class IV heart failure and severe peripheral artery disease is admitted to the intensive care unit with acute cardiogenic shock. He is currently receiving continuous intravenous infusions of norepinephrine and dobutamine. Despite these interventions, his extremities are cold and mottled, and his urine output is minimal. The attending physician informs the patient that without mechanical circulatory support, such as an intra-aortic balloon pump, he will likely die within hours to days.

The patient is fully alert, oriented to person, place, and time. He accurately repeats the clinical information back to the physician and states, "I have lived a long life and I do not want to spend my final moments hooked up to more machines. Please stop these blood pressure medications and just keep me comfortable."

Shortly after, the patient's adult daughter, who is designated as his legal healthcare proxy in a signed advance directive, arrives at the bedside. She insists that all life-sustaining measures be continued, stating, "He is just overwhelmed right now and not thinking straight. As his healthcare proxy, I authorize the mechanical support."

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

A 74-year-old man is hospitalized with severe aspiration pneumonia. His medical history is significant for progressive amyotrophic lateral sclerosis (ALS) and acute angle-closure glaucoma. He is currently wheelchair-bound and relies on non-invasive positive pressure ventilation for 18 hours daily. Over the past 24 hours, his respiratory status has deteriorated, and he is struggling to clear copious respiratory secretions.

The critical care team explains that without endotracheal intubation, he will likely progress to hypercapnic respiratory failure and die. The patient, communicating clearly via a text-to-speech device, responds: "I understand that I will die without a breathing tube. I have thought about this for months. I want to forgo intubation and antibiotics. Please just keep me comfortable so I can pass away peacefully at home."

His wife, who is his legally designated healthcare proxy, is distraught. She tells the attending physician, "He is just temporarily overwhelmed. You must intubate him and transfer him to the intensive care unit." The physician performs a thorough evaluation and determines that the patient correctly understands his prognosis, appreciates the consequences of his decision, and is reasoning consistently with his long-held values.

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

During morning rounds in the medical intensive care unit, a physician evaluates a 74-year-old woman who is being treated for severe community-acquired pneumonia and sepsis. She has a known history of focal impaired awareness seizures, which are normally well-controlled on oral phenytoin. However, due to intubation and enteral feeding intolerance upon admission three days ago, she was transitioned to an intravenous maintenance dose of phenytoin. Today, she has been successfully extubated but appears lethargic and confused. Neurologic examination reveals prominent bilateral horizontal nystagmus, dysarthria, and wide-based truncal ataxia when she is assisted to the edge of the bed.

Morning laboratory results are as follows:

A total serum phenytoin concentration obtained two hours prior to the next scheduled dose is 15 mcg/mL (reference range: 10-20 mcg/mL).

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

A 78-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) and mild cognitive impairment is being prepared for discharge home after receiving treatment for community-acquired pneumonia. He will be returning to live with his daughter. To optimize patient safety and minimize the risk of readmission, arrange the following transitional care and discharge planning steps in the most appropriate chronological sequence.

Match each end-of-life clinical scenario to the most appropriate next step in symptom management.

A 48-year-old woman presents to the clinic for a health maintenance visit. She has a history of type 2 diabetes mellitus, moderate persistent asthma, and obesity. She smoked 1 pack of cigarettes daily for 22 years but quit 5 years ago. She currently feels well and has no acute complaints. Her medications include metformin, atorvastatin, a fluticasone-salmeterol inhaler, and a levonorgestrel-releasing intrauterine device.

A review of her preventive care history reveals the following:
- Screening mammography: Performed 1 year ago (normal, BI-RADS 1)
- Screening colonoscopy: Performed 3 years ago at age 45 (normal)
- Papanicolaou (Pap) test with human papillomavirus (HPV) co-testing: Performed 3 years ago at age 45 (negative)
- Hepatitis C virus antibody test: Performed 2 years ago (negative)
- Tetanus, diphtheria, and pertussis (Tdap) vaccine: Administered 3 years ago
- Influenza vaccine: Received an inactivated influenza vaccine 2 weeks ago

The patient has never received a pneumococcal or zoster vaccine.

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