Patient Management

A 58-year-old man is preparing for discharge from the cardiac intensive care unit. He was admitted 4 days ago for ventricular tachycardia storm, experiencing multiple recurrent implantable cardioverter-defibrillator (ICD) shocks. He was stabilized on an intravenous amiodarone infusion and is now being transitioned to an oral amiodarone loading regimen (400 mg three times daily) to suppress further arrhythmias.

His past medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of 20%, permanent atrial fibrillation, mechanical mitral valve replacement 5 years ago, and stable chronic kidney disease.

His home medications, which were continued throughout his hospitalization, include warfarin 5 mg daily, digoxin 0.125 mg daily, metoprolol succinate 100 mg daily, lisinopril 20 mg daily, and furosemide 40 mg daily.

Today's laboratory results are as follows:

Which of the following is the most appropriate next step in treatment adaptation and monitoring for this patient at discharge?

A 65-year-old woman comes to the ambulatory clinic for a routine health maintenance examination. She has no acute complaints. Her medical history is notable for mild, intermittent lower back pain that is well-controlled with occasional over-the-counter ibuprofen. She went through menopause at age 52. She has never smoked, consumes alcohol occasionally, and walks 30 minutes daily. Vital signs are within normal limits. Physical examination, including a musculoskeletal assessment, shows no abnormalities. Which of the following is the most appropriate next step in management for this patient?

A 54-year-old man presents to the clinic for a routine health maintenance visit. His past medical history is significant for type 2 diabetes mellitus, well-controlled on metformin, and primary hypertension treated with lisinopril. He has a 25-pack-year smoking history but successfully quit smoking 2 years ago. He drinks alcohol socially and denies illicit drug use.

His last primary care visit was 5 years ago, during which he received a tetanus, diphtheria, and acellular pertussis (Tdap) booster. He receives an annual influenza vaccine at his local pharmacy. At age 51, he completed a two-dose series of the recombinant zoster vaccine. He has no history of pneumococcal vaccination.

A screening colonoscopy performed at age 46 revealed two diminutive hyperplastic polyps in the distal rectum, which were completely excised. He had a one-time screening test for Hepatitis C and HIV at age 48, both of which were negative.

His vital signs today are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $128/78\text{ mmHg}$, heart rate $72/\text{min}$, and respiratory rate $14/\text{min}$. BMI is $31\text{ kg/m}^2$. Physical examination is unremarkable.

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

A hospital system's medical director is reviewing disposition and care transition protocols to ensure compliance with federal guidelines. To optimize resource utilization and prevent unsafe discharges, physicians must accurately match patients to post-acute care settings based on regulatory criteria. Arrange the following care settings in descending order of their mandated medical intensity, starting from the HIGHEST level of required physician oversight and complex medical care down to the LOWEST level.

A 29-year-old woman is admitted to the medical ward for an acute flare of known ulcerative colitis. On admission, she reports 11 bloody bowel movements per day. Her vital signs show a heart rate of 115/min, blood pressure of 110/70 mm Hg, and a temperature of 38.1°C (100.6°F). Laboratory results reveal a hemoglobin of 9.8 g/dL and a C-reactive protein (CRP) of 65 mg/L. The patient is designated as having acute severe ulcerative colitis. Arrange the following steps in the optimal sequential protocol for her diagnostic evaluation, treatment monitoring, and therapeutic escalation.

A 71-year-old retired architect visits an ambulatory care center accompanied by her son for a routine follow-up. She was diagnosed with paroxysmal atrial fibrillation three months ago and was prescribed apixaban. During today's visit, she admits she stopped taking the medication a month ago. She states, "I read online that those artificial blood thinners can cause fatal bleeding. I decided to use a natural approach with high-dose Ginkgo biloba and garlic extract instead. I feel perfectly fine, and my son agrees with my choice." Her past medical history includes hypertension and type 2 diabetes mellitus. Her blood pressure is 132/82 mm Hg, and her pulse is 78/min and irregularly irregular. Which of the following is the most appropriate initial step in counseling this patient?

A 76-year-old woman is evaluated in the ambulatory care setting for a 1-week history of severe right-sided scalp pain, jaw fatigue when eating, and two episodes of transient visual obscuration in her right eye. Initial laboratory assessment reveals an erythrocyte sedimentation rate (ESR) of 88 mm/h and a C-reactive protein (CRP) level of 45 mg/L. The physician formulates a highly suspicious working diagnosis of giant cell arteritis (GCA).

Arrange the following patient management, monitoring, and therapeutic de-escalation steps in the most appropriate chronological sequence.

A 70-year-old man is admitted to the medical intensive care unit with severe septic shock secondary to ischemic bowel. He is endotracheally intubated, hemodynamically unstable, and lacks decision-making capacity. His clinical condition is rapidly deteriorating despite maximal medical therapy. The primary care team determines that a discussion regarding the potential withdrawal of life-sustaining treatment and transition to comfort-focused care is medically indicated. A thorough chart review confirms the patient has no documented advance directive and has not explicitly designated a healthcare proxy. Several individuals have arrived at the intensive care unit, each asserting their right to make medical decisions on the patient's behalf. According to the standard legal hierarchy of surrogate decision-makers in most United States jurisdictions, arrange the following individuals in the correct order of priority to act as the patient's surrogate, from highest priority (first) to lowest priority (last).

A 45-year-old man presents to the primary care clinic for a routine health maintenance examination. He has a history of hypertension and recently elevated liver enzymes. Upon taking a social history, the physician notes that the patient consumes 5 to 6 standard alcoholic beverages daily. Match each of the patient's statements, which represent different stages of readiness to change based on the Transtheoretical Model, with the most appropriate physician counseling strategy.

On hospital day 6, a 62-year-old woman admitted to the intensive care unit for a massive pulmonary embolism is evaluated for new-onset right leg swelling and pain. She has been continuously managed with an intravenous unfractionated heparin infusion since admission. Laboratory studies from day 1 showed a platelet count of $240,000/\mu L$. Today's routine morning laboratory results reveal a platelet count of $90,000/\mu L$ and an activated partial thromboplastin time (aPTT) of 45 seconds (institutional therapeutic range: 60-80 seconds). A lower extremity venous duplex ultrasound is performed and demonstrates a new, completely occlusive thrombus in the right femoral vein. Which of the following is the most appropriate next step in the management of this patient's anticoagulation therapy?

Match each patient statement regarding lifestyle modification (representing a specific stage in the Transtheoretical Model of Change) to the most appropriate initial physician counseling strategy.

An asymptomatic $69$-year-old male visits his primary care physician for a scheduled health maintenance examination. His medical history includes only mild osteoarthritis of the knees. The patient states that he smoked one pack of cigarettes daily starting at age $18$ but successfully quit on his $45$ th birthday. His blood pressure is $122/78$ mm Hg, heart rate is $72$/min, and body mass index is $24$ kg/m $^2$. Cardiopulmonary and abdominal examinations reveal no abnormalities. Based on current guidelines, which of the following is the most appropriate screening intervention for this patient?

A 68-year-old man is evaluated for care transition on hospital day 24. He was initially admitted to the intensive care unit (ICU) for severe acute pancreatitis complicated by acute respiratory distress syndrome and acute kidney injury. His hospital course was prolonged, requiring vasopressor support for 12 days and initiation of intermittent hemodialysis.

Current status:
- He has been hemodynamically stable without vasopressors for 10 days.
- A tracheostomy was performed on hospital day 14. He remains on mechanical ventilation on pressure support mode but is actively being weaned.
- Nutrition is provided via a percutaneous endoscopic gastrostomy (PEG) tube.
- He continues to require hemodialysis three days a week.
- Neurologically, he is alert, follows complex commands, and communicates by using a letter board.
- He has profound ICU-acquired weakness. He requires maximal assistance for all bed mobility and fatigues after 15 minutes of sitting on the edge of the bed with physical therapy.

The critical care team determines he no longer requires ICU-level monitoring. Which of the following is the most appropriate care setting for this patient's disposition?

A 60-year-old woman is evaluated in the intensive care unit on day 10 of her hospitalization. She was initially admitted for an acute submassive pulmonary embolism and started on a continuous intravenous unfractionated heparin infusion. On hospital day 6, her platelet count dropped abruptly from a baseline of 240,000/mm³ to 70,000/mm³. Heparin-induced thrombocytopenia (HIT) was suspected; heparin was immediately discontinued, and a continuous intravenous infusion of argatroban was initiated. Subsequent enzyme-linked immunosorbent assay (ELISA) and serotonin release assay (SRA) confirmed the diagnosis of HIT.

Laboratory results over the last few days are as follows:

The patient is clinically stable with no signs of active bleeding or recurrent thrombosis. The care team plans to transition her to oral warfarin for long-term anticoagulation. Which of the following is the most appropriate protocol for monitoring and evaluating this patient's transition to oral warfarin therapy?

A $41$-year-old woman is evaluated in the rheumatology clinic for follow-up of newly diagnosed rheumatoid arthritis. Two weeks ago, she was started on oral methotrexate and daily folic acid supplementation. She reports mild nausea but otherwise feels well. Physical examination shows mild swelling in the metacarpophalangeal joints of both hands, which is improved from her previous visit. As part of her ongoing maintenance therapy, which of the following routine evaluations are necessary to monitor for potential adverse effects of her primary disease-modifying medication? (Select all that apply)

A 54-year-old woman is evaluated in the oncology clinic at 4:00 PM for a fever. She has a history of estrogen receptor-positive breast cancer and received her second cycle of adjuvant docetaxel and cyclophosphamide 8 days ago. She reports mild fatigue and chills but denies cough, shortness of breath, abdominal pain, diarrhea, or dysuria. She lives entirely alone on a rural farm approximately 90 miles (145 km) from the nearest hospital or urgent care facility. She drove herself to the clinic today because she happened to be in town for errands. Her temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is 118/76 mm Hg, pulse is 88/min, and respirations are 16/min. Physical examination, including inspection of the central venous port site, shows no abnormalities. Laboratory studies show:

Leukocyte count: $800/\text{mm}^3$
Neutrophils: $10\%$
Hemoglobin: 11.2 g/dL
Platelets: $125,000/\text{mm}^3$
Creatinine: 0.8 mg/dL
Total bilirubin: 0.7 mg/dL

Based on objective risk stratification and the patient's current status, which of the following is the most appropriate disposition and care transition for this patient?

A 38-year-old man is admitted to the hospital with a 1-week history of severe fatigue, easy bruising, and gingival bleeding. Laboratory evaluation reveals a leukocyte count of $3,500/\text{mm}^3$, hemoglobin of $8.2\text{ g/dL}$, and platelet count of $22,000/\text{mm}^3$. Coagulation studies demonstrate a prothrombin time of 18 seconds, activated partial thromboplastin time of 45 seconds, and a fibrinogen level of $90\text{ mg/dL}$. Bone marrow aspiration and cytogenetics confirm the presence of a $t(15;17)$ translocation. The patient is diagnosed with low-risk acute promyelocytic leukemia and is scheduled to begin induction therapy with all-trans retinoic acid and arsenic trioxide. A baseline electrocardiogram shows a QTc interval of $415\text{ ms}$. Which of the following are REQUIRED components of the monitoring and treatment evaluation protocol for this patient's new pharmacotherapy? (Select all that apply)

A 54-year-old woman is admitted to an inpatient hospice facility for the management of intractable symptoms secondary to terminal metastatic cervical cancer. Her clinical course is complicated by a malignant bowel obstruction, rendering her completely intolerant to enteral intake. Over the past 48 hours, she has experienced relentless nausea, frequent large-volume emesis, and diffuse abdominal pain. These symptoms have persisted despite maximally tolerated continuous intravenous infusions of hydromorphone, haloperidol, and octreotide, as well as scheduled intravenous dexamethasone. On examination, the patient is cachectic, visibly distressed, crying, and writhing in bed. Her estimated prognosis is hours to a few days. During the bedside evaluation, the patient clearly states, "I cannot take this agony anymore. Please just put me to sleep so I do not have to suffer until the end." The physician assesses that the patient fully understands her condition and the consequences of her request. Which of the following is the most appropriate next step in management?

A 55-year-old patient with newly diagnosed chronic obstructive pulmonary disease is seen in the primary care clinic. She continues to smoke one pack of cigarettes daily. When the topic of smoking cessation is raised, she states, "I know smoking is worsening my lungs, but my job as a project manager is incredibly stressful right now, and cigarettes are the only way I can cope." The physician plans to utilize the core principles of Motivational Interviewing to address her tobacco use. Arrange the following physician responses in the correct chronological sequence to appropriately execute the four fundamental processes of Motivational Interviewing.

During a scheduled wellness evaluation, a 68-year-old woman is seen in the outpatient clinic. She reports feeling well and has no new symptomatic complaints. Her active medical problems include essential hypertension and osteoarthritis, both of which are well-controlled. Her surgical history is notable for a total abdominal hysterectomy with bilateral salpingo-oophorectomy performed at age 65 for symptomatic uterine leiomyomas. Several years prior to that procedure, at age 57, she underwent a loop electrosurgical excision procedure for cervical intraepithelial neoplasia 3 (CIN 3) with clear margins. Subsequent follow-up testing prior to her hysterectomy was negative.

She has a 30-pack-year smoking history but successfully quit 18 years ago. She consumes alcohol rarely and exercises three times weekly. Recent preventive care includes a normal screening mammogram 6 months ago, a normal screening colonoscopy at age 62, and a normal dual-energy x-ray absorptiometry scan at age 65. Her immunizations, including recombinant zoster, pneumococcal, and seasonal influenza vaccines, are up to date. Vital signs today are within normal limits.

Which of the following screening recommendations is most appropriate for this patient at this visit?