Patient Management

Match each end-of-life clinical scenario or surrogate decision-making context with the corresponding ethical standard or advance care planning tool.

A 48-year-old man comes to the emergency department reporting four days of fever, chills, and a cough productive of yellowish sputum. He has no significant past medical history and takes no daily medications. Vital signs are temperature 38.1°C (100.6°F), blood pressure 122/78 mm Hg, pulse 92/min, and respiratory rate 16/min. Pulse oximetry shows 97% on room air. Physical examination reveals bronchial breath sounds and crackles over the left lower lung field. Laboratory testing shows a leukocyte count of 11,200/mm³ and a blood urea nitrogen of 14 mg/dL. Chest radiography confirms a left lower lobe consolidation consistent with community-acquired pneumonia. The physician determines the patient is at low medical risk and is clinically appropriate for oral antibiotic therapy. However, upon discussing discharge planning, the patient states he was evicted two weeks ago, is currently sleeping in his vehicle, has no health insurance, and possesses only a few dollars. Which of the following is the most appropriate disposition plan for this patient?

During a comprehensive health maintenance examination, a physician evaluates a 55-year-old female patient who reports a persistent morning cough. History reveals she has consumed one pack of cigarettes daily for three decades. The clinician decides to implement the US Preventive Services Task Force (USPSTF) recommended behavioral framework for tobacco cessation.

Arrange the following physician actions in the correct sequential order according to this evidence-based framework.

An 82-year-old woman is admitted with a severe ischemic stroke and is now deemed medically stable for discharge. She has profound expressive aphasia and cognitive deficits, rendering her unable to participate in complex medical decision-making. The multidisciplinary team determines she requires intensive physical rehabilitation and 24-hour nursing care. Arrange the following steps in the most appropriate chronological order to facilitate a safe, ethical, and effective transition of care.

A 48-year-old man who underwent a deceased-donor kidney transplant 3 years ago is evaluated in the clinic. He reports a 3-day history of a white coating in his mouth. He denies dysphagia, odynophagia, or fever. His current maintenance immunosuppressive regimen includes tacrolimus, mycophenolate mofetil, and prednisone. His allograft function has been stable with a baseline serum creatinine of $1.2\text{ mg/dL}$. Today, his temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$). Physical examination reveals adherent white plaques on the buccal mucosa and tongue that can be easily scraped off. Laboratory studies obtained today show a serum creatinine of $1.3\text{ mg/dL}$ and a tacrolimus trough level of $6.5\text{ ng/mL}$ (target: $5-8\text{ ng/mL}$). The physician diagnoses oropharyngeal candidiasis and plans to prescribe a 14-day course of oral fluconazole. The patient also mentions he forgot to get his annual influenza vaccine and requests it during this visit. Which of the following is the most appropriate next step in the management of this patient?

A 58-year-old man with poorly controlled type 2 diabetes mellitus (HbA1c 10.4%) presents for a follow-up visit. He has repeatedly declined insulin therapy in the past, citing a fear of needles and a belief that starting insulin means he has 'failed' at managing his health. The physician decides to utilize the formal, four-process framework of Motivational Interviewing to guide the consultation.

Arrange the following physician statements in the correct chronological sequence reflecting the standard progression of Motivational Interviewing (Engaging, Focusing, Evoking, and Planning).

A 54-year-old man is evaluated in the clinic for a new-onset tremor and diffuse headaches that began 5 days ago. He underwent a deceased-donor renal transplantation 8 months ago for end-stage renal disease secondary to hypertensive nephrosclerosis. His maintenance immunosuppressive regimen consists of tacrolimus, mycophenolate mofetil, and low-dose prednisone. Two weeks ago, he was diagnosed with paroxysmal atrial fibrillation; at that time, his primary care physician initiated therapy with diltiazem and apixaban.

On physical examination, blood pressure is 142/88 mmHg and pulse is 78/min and irregularly irregular. A coarse resting tremor is observed in the bilateral upper extremities. The remainder of the examination is unremarkable.

Laboratory studies show:
Serum sodium: 139 mEq/L
Serum potassium: 5.1 mEq/L
Serum chloride: 104 mEq/L
Serum bicarbonate: 22 mEq/L
Blood urea nitrogen: 48 mg/dL
Serum creatinine: 2.6 mg/dL (baseline 1.2 mg/dL)
Serum tacrolimus trough level: 24 ng/mL (target: 5-8 ng/mL)

Renal ultrasound reveals a normal-appearing allograft with no hydronephrosis and normal resistive indices.

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

Establishing care for a new primary care physician, a 72-year-old biological male is evaluated in the ambulatory setting to discuss his health maintenance plan. He has a 45 pack-year history of cigarette smoking but successfully achieved cessation 12 years ago. His medical history includes severe chronic obstructive pulmonary disease requiring continuous home oxygen therapy, as well as New York Heart Association class III heart failure with a left ventricular ejection fraction of 25%. Current medications include sacubitril-valsartan, carvedilol, spironolactone, empagliflozin, and multiple inhaled therapies. His most recent colonoscopy at age 65 was unremarkable, and he received the 20-valent pneumococcal conjugate vaccine last year. When discussing preventive cancer screening, the patient inquires about his risk for lung cancer and whether he should undergo imaging. Based on current guidelines, which of the following is the most appropriate recommendation regarding lung cancer screening for this patient?

A 72-year-old man with end-stage heart failure secondary to ischemic cardiomyopathy is admitted to the inpatient hospice unit. He has an implantable cardioverter-defibrillator (ICD) that also provides biventricular pacing. Over the past week, his condition has deteriorated significantly; he is now bedbound and requires continuous intravenous morphine for severe resting dyspnea. He remains fully alert, oriented, and capable of communicating his wishes. Today, he experienced three painful ICD shocks for episodes of ventricular tachycardia. He tells the attending physician, "These shocks are agonizing. Please turn this machine off so I can pass peacefully." The patient's wife expresses deep distress and states, "I want him to be comfortable, but isn't turning off his heart device the same as physician-assisted suicide? Can't we just give him medication for the rhythm instead?" Which of the following is the most appropriate next step in management?

A 72-year-old man is evaluated in the emergency department for a 2-day history of productive cough, subjective fevers, and increasing fatigue. His medical history is significant for hypertension and benign prostatic hyperplasia. He lives alone in a second-story apartment with no elevator.

Vital signs are:
- Temperature: 38.1°C (100.6°F)
- Blood pressure: 128/78 mmHg
- Heart rate: 92/min
- Respiratory rate: 18/min
- Oxygen saturation: 95% on room air

Laboratory studies reveal:
- Leukocyte count: 11,500/mm³
- Blood urea nitrogen: 16 mg/dL
- Serum creatinine: 1.0 mg/dL

Chest radiography demonstrates a left lower lobe consolidation. The patient is alert and fully oriented. Based on objective scoring systems (e.g., CURB-65 score of 1, Pneumonia Severity Index Class II), his medical severity suggests he could be safely treated as an outpatient.

However, during the evaluation, the patient demonstrates profound generalized weakness. He requires the assistance of two staff members to transfer from the stretcher to a bedside chair and is unable to ambulate independently. When the physician discusses the care plan, the patient asks, "Can't I just go home with some pills?" but states he will follow the physician's medical advice.

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

An ambulatory care clinic evaluates a 54-year-old biological male for a routine health maintenance visit. His past medical history is notable for well-controlled type 2 diabetes mellitus and primary hypertension. The patient smoked one pack of cigarettes daily for 25 years but successfully quit 4 years ago. He does not consume alcohol or use recreational drugs. His immunizations are up to date, including a Tdap booster received 3 years ago and a complete two-dose series of the recombinant zoster vaccine administered at age 50. He has never received a pneumococcal vaccination. A review of his electronic medical record shows a screening colonoscopy performed at age 47 that revealed no polyps or abnormalities. He has no history of recent chest imaging or abdominal ultrasonography. He currently feels well and reports no new symptoms. Which of the following preventive interventions are indicated for this patient during today's visit? (Select all that apply)

Match each clinical scenario to the most appropriate disposition or care setting.

Match each patient's clinical presentation with the most appropriate post-acute care disposition setting based on standard utilization and functional criteria.

An independent senior living facility resident presents to her primary care physician for a scheduled medication review. The patient is 71 years old and has a medical history significant for paroxysmal atrial fibrillation, osteoarthritis, and osteoporosis. Three weeks ago, a cardiologist prescribed dabigatran for stroke prophylaxis. Today, the patient brings all her medication bottles in a bag and states, "I am terrified of this new blood thinner. I read online that it causes fatal bleeding. I have decided to stop taking it and instead use St. John's wort and my usual high-dose ibuprofen." She demonstrates a clear understanding of her medical conditions and the basic purpose of her medications.

Which of the following is the most appropriate initial statement by the physician?

A $52$-year-old man presents to the clinic for a general health assessment. He was recently hired for a new job and wishes to ensure his immunizations and screenings are up to date, noting he has not seen a healthcare provider since he was $46$ years old. He has no physical complaints and takes no prescription medications. He has smoked $1$ pack of cigarettes daily since age $22$. His body mass index is $32 \text{ kg/m}^2$, and his blood pressure is $126/78 \text{ mmHg}$. A review of his past medical records reveals a negative fourth-generation HIV test, a negative hepatitis C antibody test, and a normal screening colonoscopy, all performed $6$ years ago. Based on current guidelines, which of the following preventive interventions are indicated for this patient during today's visit? (Select all that apply)

An 82-year-old woman is evaluated on the medical floor to finalize her discharge plan. She was admitted 6 days ago for an acute right middle cerebral artery ischemic stroke. Her past medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus. Her current medications include aspirin, atorvastatin, lisinopril, and metformin. She is medically stable, and her vital signs are within normal limits. Her basic metabolic panel is notable for a serum sodium of 133 mEq/L, which is unchanged from her baseline value from 6 months ago. The remainder of her laboratory results are normal.

Neurologic examination shows a dense left-sided hemiparesis and left-sided spatial neglect. She requires maximum assistance for transfers and most activities of daily living. A physical therapy evaluation notes that the patient is highly motivated and follows commands well. However, she currently tolerates a maximum of 45 to 60 minutes of combined physical and occupational therapy per day due to significant post-stroke fatigue. Prior to this admission, she lived alone in a single-story home and was completely independent. Her son, who is her healthcare proxy, is heavily involved and asks about the next steps in her care.

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

A 28-year-old man is diagnosed with his first episode of uncomplicated major depressive disorder. After shared decision-making, he is started on oral escitalopram 10 mg daily. He has no history of psychiatric hospitalizations, suicide attempts, or substance use disorders. Assuming the patient experiences an uncomplicated clinical course with eventual full remission and no severe adverse effects, arrange the following clinical management and monitoring steps in the correct chronological sequence.

A hospital care team is coordinating the disposition of a 34-year-old man who has been receiving inpatient treatment for methicillin-resistant Staphylococcus aureus (MRSA) tricuspid valve endocarditis. He was admitted 14 days ago after presenting with fever and pleuritic chest pain. His hospital course was initially complicated by septic pulmonary emboli, but he has been afebrile and hemodynamically stable for the past week. His blood cultures have been negative for 10 days, and a repeat echocardiogram shows a decrease in the size of the tricuspid vegetation with no new complications. The patient has a documented history of severe opioid use disorder involving intravenous heroin. He is currently stabilized on buprenorphine-naloxone therapy, which was initiated during this admission. The infectious disease service determines he requires 4 more weeks of antimicrobial therapy. The patient is eager to leave the hospital, stating he has stable housing with his parents and reliable transportation to appointments. Which of the following is the most appropriate disposition and transition of care plan for this patient?

A 75-year-old man is hospitalized with a severe exacerbation of end-stage chronic obstructive pulmonary disease (COPD). Over the past year, he has had four hospitalizations and two intensive care unit admissions for hypercapnic respiratory failure. Despite maximal medical therapy, including continuous home oxygen, inhaled bronchodilators, and systemic glucocorticoids, he remains markedly dyspneic at rest. During morning rounds, the patient clearly and consistently states, "I cannot keep living like this. I want to go home and focus entirely on my comfort. I do not want to return to the hospital ever again." His son, who is visiting from out of state, becomes visibly upset and tells the physician, "You cannot let him do this. He is just depressed and legally incompetent to make this choice because of his illness. He needs to go to a pulmonary rehabilitation facility." The physician evaluates the patient and finds that he is alert, oriented, and understands his prognosis. He clearly articulates the risks, benefits, and rationale for his decision without any clinical evidence of depression affecting his judgment. Which of the following is the most appropriate next step in management?

A retired accountant accompanied by his adult son arrives for a scheduled health maintenance visit. The 67-year-old patient has a documented history of type 2 diabetes mellitus, essential hypertension, and a myocardial infarction that occurred two years prior. His current prescribed regimen includes metformin, metoprolol, and atorvastatin. During the encounter, the son expresses significant frustration, noting that his father frequently skips his daily medications. When the physician inquires about this behavior, the patient crosses his arms and states, 'I feel perfectly fine. I do not see why I need to swallow a handful of chemicals every morning when I am not even sick.' Which of the following is the most appropriate initial communication strategy by the physician?