Patient Management

Determine the most appropriate validated risk stratification tool used to guide the immediate care setting disposition (e.g., safe outpatient discharge versus hospital admission) for each clinical scenario. Match each patient presentation to its corresponding disposition tool.

A 78-year-old man is evaluated for discharge planning on hospital day 12 following admission for a severe acute ischemic stroke. His hospital course was complicated by aspiration pneumonia, which has now fully resolved after a 7-day course of intravenous antibiotics. His medical history includes moderate chronic obstructive pulmonary disease (COPD) and hypertension.

Currently, the patient is hemodynamically stable and his oxygen saturation is 95% on room air. Neurological examination shows dense left-sided hemiparesis and left homonymous hemianopia. He has moderate oropharyngeal dysphagia but is safely tolerating a mechanical soft diet with thickened liquids.

Physical and occupational therapy evaluations indicate that he requires maximal assistance for bed mobility and transfers from bed to chair. He is cognitively intact, highly motivated, and actively participates in his rehabilitation sessions. However, due to dyspnea from his underlying COPD and generalized deconditioning, he experiences severe exhaustion and can only participate in 60 to 90 minutes of combined therapy per day before requiring prolonged rest.

He lives in a single-story home with his 76-year-old wife, who has severe rheumatoid arthritis and is physically unable to assist with his transfers. The patient has standard Medicare coverage and limited out-of-pocket financial resources.

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

A $42$-year-old female with a history of bipolar disorder is brought to the emergency department by her family due to progressively worsening lethargy, coarse tremors, and severe ataxia over the past three days. She has been stable on lithium carbonate for five years but was recently prescribed lisinopril for hypertension by her primary care physician. Initial laboratory evaluation reveals a serum lithium concentration of $3.8 \text{ mEq/L}$ and a serum creatinine of $2.4 \text{ mg/dL}$ (baseline $0.9 \text{ mg/dL}$). Arrange the following therapeutic and monitoring actions in the most appropriate chronological sequence for managing this patient's condition.

A 22-year-old woman is brought to the emergency department by her roommate 2 hours after intentionally ingesting an unknown quantity of acetaminophen. She is currently asymptomatic. Her vital signs are within normal limits, and her physical examination is unremarkable. Intravenous access is established. Arrange the following steps in the most appropriate chronological order for evaluating and monitoring this patient's potential acetaminophen toxicity.

An 82-year-old woman is evaluated for discharge planning. She was admitted 4 days ago for an acute kidney injury secondary to poor oral intake and dehydration, which has fully resolved with intravenous fluids. During the hospitalization, the medical team notes significant cognitive deficits. A Montreal Cognitive Assessment (MoCA) score is 15/30. Her daughter, who lives in another state and cannot provide direct care, arrives and reports that the patient has recently been getting lost in her own neighborhood, forgetting to pay bills, and leaving the stove burner on unattended. The patient currently lives alone in a single-story house.

Physical and occupational therapy evaluations determine that the patient is independently ambulatory without an assistive device. She is physically capable of transferring, bathing, and dressing herself, although she requires frequent verbal cueing to initiate and complete these tasks. She takes only oral medications for hypertension and hypothyroidism. She does not require any intravenous medications, wound care, or ongoing physical therapy. Both the patient and her daughter agree that the patient can no longer safely live alone and wish to transition her to an appropriate facility.

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

A primary care physician is reviewing the electronic health records of four established patients who are scheduled for annual health maintenance visits this morning. Match each patient's specific clinical presentation to the single most appropriate, guideline-concordant screening intervention that should be ordered or performed today.

A $38$-year-old male nurse is evaluated during a routine follow-up visit. Six weeks ago, he was diagnosed with latent tuberculosis infection after routine occupational screening revealed a positive interferon-gamma release assay. A chest radiograph at that time was normal. He was started on a daily regimen of isoniazid and pyridoxine. Prior to initiating therapy, his baseline hepatic transaminase levels and bilirubin were within normal limits.

Today, he reports that he feels well, exercises three times a week, and has no fatigue, nausea, vomiting, or abdominal pain. He drinks one glass of wine occasionally but has not consumed any alcohol in the past two weeks. Physical examination shows an anicteric patient with a non-tender abdomen and no hepatomegaly.

Current laboratory studies are as follows:

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

An asymptomatic 67-year-old woman visits her primary care physician to review her preventive health needs. Her past medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy performed 12 years ago for cervical intraepithelial neoplasia grade 3 (CIN 3). She takes amlodipine daily.

She has a 54 pack-year smoking history but successfully quit 16 years ago. She consumes a glass of wine on weekends and denies any illicit drug use.

Her records indicate the following recent preventive evaluations:
- Screening colonoscopy at age 61 revealed no polyps.
- Screening mammography 6 months ago was interpreted as normal (BI-RADS 1).
- Dual-energy x-ray absorptiometry scan at age 65 showed a T-score of -1.4 at the lumbar spine and -1.2 at the femoral neck.
- Her most recent vaginal cuff cytology combined with human papillomavirus co-testing was performed 4 years ago and was negative.
- She received the 20-valent pneumococcal conjugate vaccine and a two-dose recombinant zoster vaccine series at age 65. She had her annual influenza vaccination 1 month ago.

Physical examination today is unremarkable. Her blood pressure is 128/78 mmHg, and her body mass index is 26 kg/m².

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

A $45$-year-old man comes to the clinic for a routine follow-up visit. Four weeks ago, he was diagnosed with active pulmonary tuberculosis and started on a daily regimen of isoniazid, rifampin, pyrazinamide, and ethambutol, along with pyridoxine. He reports feeling much better, with resolution of his initial fever, night sweats, and cough. He specifically denies any abdominal pain, nausea, vomiting, dark urine, or unusual fatigue. He has no history of liver disease and does not consume alcohol. Vital signs are within normal limits. Physical examination shows no scleral icterus, and the abdomen is soft and non-tender with no hepatomegaly.

Which of the following is the best next step in patient management?

A 35-year-old woman comes to the primary care clinic for a routine follow-up visit. Two months ago, she was diagnosed with an unprovoked deep vein thrombosis of the right lower extremity and was appropriately started on rivaroxaban. She has no other medical conditions and takes no other medications. During the interview, she appears visibly distressed and states, "I have been feeling very down and overwhelmed since my diagnosis, so I plan to start taking an over-the-counter St. John's wort supplement to improve my mood. Additionally, my aunt told me that because I am on a strong blood thinner, I need a screening head MRI to check for hidden bleeding, and she said I should start getting annual mammograms immediately to be safe." Which of the following is the most appropriate initial counseling response by the physician?

A 58-year-old woman with a history of recurrent major depressive disorder and newly diagnosed nonvalvular atrial fibrillation presents to the clinic for a follow-up visit. She is currently taking citalopram. At her last visit, apixaban was prescribed for stroke prophylaxis. Today, she informs the physician, "I threw that prescription away. I don't want to take synthetic chemicals. I have decided to manage my heart condition naturally with St. John's wort and a daily aspirin instead." The patient is alert, oriented, and correctly states that not taking apixaban increases her risk of an ischemic stroke, but she says she accepts this risk. Which of the following is the most appropriate next step in management?

A 58-year-old cisgender male presents to the clinic to establish care. He reports feeling well and has no acute symptoms. His past medical history is notable for HIV infection, diagnosed 10 years ago, and essential hypertension. He is currently maintained on a daily antiretroviral regimen of bictegravir, emtricitabine, and tenofovir alafenamide, with a most recent CD4 count of 520 cells/mm³ and an undetectable viral load. He has a 30-pack-year smoking history but successfully quit 5 years ago. His last preventive health visit was 3 years ago, during which he underwent a screening colonoscopy with normal findings. His vaccination records confirm receipt of a Tdap booster 3 years ago and an inactivated influenza vaccine 2 weeks ago. He has never received any pneumococcal or herpes zoster vaccines. Vital signs and physical examination today are unremarkable.

Which of the following preventive interventions are currently indicated for this patient? (Select all that apply)

A 62-year-old woman is evaluated at home by a hospice physician for severe abdominal pain and vomiting. She has widely metastatic ovarian cancer complicated by extensive peritoneal carcinomatosis. Two weeks ago, she transitioned to home hospice care with the explicit goal of maximizing comfort. She strongly refuses any hospitalizations, surgical interventions, or invasive procedures, including nasogastric intubation.

For the past 48 hours, she has had worsening colicky abdominal pain, significant nausea, and multiple episodes of large-volume, bilious emesis. Her last bowel movement was four days ago. Her current medications include a continuous subcutaneous morphine infusion for baseline pain control.

Vital signs show a heart rate of 110/min and a blood pressure of 90/60 mmHg. Physical examination reveals a visibly distended abdomen that is tympanic to percussion. Bowel sounds are high-pitched and tinkling. The physician diagnoses a malignant mechanical bowel obstruction.

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

A 48-year-old man presents to the outpatient clinic to discuss the results of a recent excisional biopsy of a suspicious pigmented skin lesion. The pathology report confirms invasive malignant melanoma with positive margins. The physician prepares to deliver this diagnosis to the patient.

Arrange the following physician statements in the most appropriate chronological sequence for delivering this diagnosis, according to the standard consensus protocol for breaking bad news.

A $65$-year-old man with symptomatic heart failure with reduced ejection fraction (LVEF $30\%$) is evaluated in the clinic. He is currently taking lisinopril, metoprolol succinate, and spironolactone. His blood pressure is $118/75$ mmHg, and his heart rate is $68$/min. A basic metabolic panel shows a serum potassium of $4.6$ mEq/L and a serum creatinine of $1.2$ mg/dL. To further optimize his guideline-directed medical therapy, the physician decides to replace lisinopril with sacubitril-valsartan.

Which of the following are required steps in the execution and monitoring of this treatment transition? (Select all that apply)

During a comprehensive health evaluation, a 38-year-old female patient inquires about her cancer risk. She currently feels well and has no physical complaints. Her medical history includes well-controlled asthma, for which she uses an albuterol inhaler as needed. She exercises regularly and follows a balanced diet.

Upon reviewing her family pedigree, the physician notes that her father was diagnosed with breast cancer at age 55, and her paternal grandmother died from ovarian cancer at age 62. Her mother and two younger sisters are alive and healthy. The patient has one child, whom she breastfed for 6 months. A thorough physical examination today, including a detailed clinical breast examination, reveals no palpable masses, skin changes, or axillary lymphadenopathy.

Based on current preventive care guidelines, which of the following is the most appropriate next step in management regarding this patient's cancer risk?

Match each patient's clinical presentation with the most appropriate next step in preventive care according to current guidelines.

A 66-year-old man presents to the clinic for a follow-up visit. Three weeks ago, he was diagnosed with a left lower extremity unprovoked deep vein thrombosis. He was initially treated with low-molecular-weight heparin and subsequently transitioned to oral warfarin. Today, his international normalized ratio (INR) is subtherapeutic at 1.3. When asked about his medication adherence, the patient states, "I have been skipping doses because my leg feels perfectly fine, and I read online that blood thinners are basically rat poison. Instead, I am taking a high-dose ginseng extract and a vitamin K-rich multivitamin to dissolve the clot naturally." Furthermore, he insists on canceling his screening colonoscopy scheduled for next week, stating he refuses any procedure requiring sedation. His wife, who is present, is highly distressed and demands that the physician immediately declare him legally unfit to make medical decisions due to his dangerous nonadherence. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical scenario with the most appropriate disposition and care setting.

An occupational health clinic evaluates a prospective employee who is completing his onboarding physical. The patient is $41$ years of age and reports a history of mild intermittent asthma, for which he uses an albuterol inhaler occasionally. He weighs $105$ kg ($231$ lbs) and is $178$ cm ($5$ ft $10$ in) tall, giving him a body mass index (BMI) of $33$ kg/m $^2$. He currently smokes $1$ pack of cigarettes per day and has done so since age $19$. He states he has not undergone any medical evaluations or received any vaccinations since high school. Which of the following preventive health interventions are definitively indicated for this patient at today's visit? (Select all that apply)