Patient Management

A $68$-year-old man is evaluated in the cardiology clinic for a follow-up of heart failure with reduced ejection fraction. His left ventricular ejection fraction is $32\%$. He is currently treated with sacubitril-valsartan, carvedilol, and furosemide. He reports mild exertional dyspnea but denies orthopnea or peripheral edema. Current vital signs are blood pressure $118/75\text{ mmHg}$ and heart rate $64\text{/min}$.

The physician decides to initiate spironolactone to further optimize his heart failure regimen. The patient is counseled on the new medication. Which of the following laboratory parameters are strictly recommended to be monitored $1$ to $2$ weeks after initiating this specific therapy? (Select 2)

A 58-year-old man with a history of nonischemic cardiomyopathy is evaluated during a routine follow-up appointment. His left ventricular ejection fraction was $28\%$ on an echocardiogram performed 1 week ago. The patient reports stable but persistent exertional dyspnea (New York Heart Association class II). His current daily medications include maximally tolerated lisinopril, carvedilol, dapagliflozin, and spironolactone. His vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $118/76\text{ mmHg}$, and heart rate $68\text{/min}$. Physical examination reveals clear lungs and trace bilateral pedal edema. Laboratory studies show a serum potassium of $4.2\text{ mEq/L}$ and creatinine of $1.1\text{ mg/dL}$. The physician plans to discontinue lisinopril and initiate sacubitril-valsartan to optimize guideline-directed medical therapy.

Which of the following are required components of the transition protocol and short-term monitoring plan for this patient? (Select 2)

A 42-year-old woman is brought to the emergency department by emergency medical services after collapsing and exhibiting generalized tonic-clonic motor activity. Upon arrival, she remains unresponsive with continuous rhythmic jerking of her extremities. Her husband states the seizure began approximately 12 minutes prior to arrival and has not ceased at any point. She has no known medical history and takes no medications. Vital signs show a temperature of 37.8°C (100.0°F), blood pressure of 135/85 mmHg, pulse of 118/min, and respirations of 18/min. Point-of-care blood glucose is 105 mg/dL. Two large-bore intravenous lines are rapidly established.

Arrange the following pharmacologic interventions in the correct protocolized sequence for the escalation of therapy in this patient, from initial first-line stabilization to the management of super-refractory symptoms.

A $42$-year-old premenopausal woman presents to the oncology clinic for a scheduled evaluation prior to her next infusion. She is currently undergoing treatment for early-stage, HER2-amplified, estrogen receptor-negative breast cancer. She successfully completed a course of adjuvant paclitaxel and is currently receiving maintenance intravenous trastuzumab every $3$ weeks.

During the clinical interview, the patient reports feeling well and denies shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, or peripheral swelling. She exercises moderately for $45$ minutes most days of the week without limitation. Vital signs include a blood pressure of $118/74$ mmHg and a heart rate of $72$/min. Physical examination reveals clear lungs bilaterally, no jugular venous distention, and a regular heart rate with no S3 gallop.

As part of her routine surveillance, serial echocardiography has been performed with the following results:

Based on the patient's surveillance data, which of the following is the most appropriate next step in management?

A 66-year-old woman comes to the clinic for a routine health maintenance examination. She feels well and has no acute complaints. Her medical history is notable for mild primary hypertension, which is well controlled on lisinopril. She does not use tobacco, alcohol, or illicit substances. She has been in a mutually monogamous relationship with her husband for 40 years.

Review of her medical records reveals the following:
- Screening mammography at age 65 was normal.
- Screening colonoscopy at age 60 showed no polyps.
- Dual-energy x-ray absorptiometry at age 65 showed normal bone mineral density.
- Cervical cancer screening via cytology and high-risk human papillomavirus (hrHPV) co-testing was performed at ages 59 and 64; both results were negative.
- She received the 20-valent pneumococcal conjugate vaccine (PCV20) at age 65.
- She received a two-dose series of the recombinant zoster vaccine at age 65.
- She received a Tdap booster at age 61.
- Medical records indicate she has never been screened for hepatitis C.

Vital signs and physical examination findings are within normal limits. Which of the following is the most appropriate next step in preventive care for this patient?

A $64$-year-old man with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia is evaluated in the outpatient clinic for a routine follow-up. He feels well and reports no new symptoms, including no changes in urine output or peripheral edema. His current medications include metformin $1000\text{ mg}$ twice daily, empagliflozin $10\text{ mg}$ daily, lisinopril $20\text{ mg}$ daily, and atorvastatin $40\text{ mg}$ daily. Vital signs show a blood pressure of $130/80\text{ mmHg}$ and a heart rate of $72/\text{min}$. Physical examination is unremarkable.

Laboratory results from the current and previous visits are shown below:

Based on these findings, which of the following is the most appropriate next step in management?

During an evaluation for treatment-resistant hypertension, diaphoresis, and episodic tachycardia, a patient is found to have significantly elevated $24$-hour urine fractionated metanephrines. Subsequent cross-sectional abdominal imaging confirms a unilateral $4.5$-cm adrenal mass, establishing the diagnosis of a pheochromocytoma. A multidisciplinary team plans a definitive surgical intervention.

Arrange the following perioperative management steps in the mandatory chronological order required to safely optimize the patient and prevent catastrophic hemodynamic instability.

A 72-year-old man comes to the clinic to establish care. He recently moved to the area to live closer to his daughter and has not seen a physician in over 10 years. His past medical history includes hypertension, which is well controlled on amlodipine. He smoked one pack of cigarettes daily from age 20 to 55 but has not smoked since. He drinks alcohol occasionally. His blood pressure is 128/82 mmHg, pulse is 72/min, and BMI is 24 kg/m². Physical examination is unremarkable. He has not undergone any cancer screening or preventive testing in the past decade. Based on current guidelines, which of the following preventive interventions are indicated for this patient today? (Select all that apply)

An 82-year-old man who resides in a skilled nursing facility is evaluated in the emergency department for a two-day history of progressively worsening abdominal pain, an inability to pass flatus, and recurrent bilious vomiting. He has a history of Parkinson disease, chronic constipation, and hypertension. His daily medications include carbidopa-levodopa, lisinopril, and polyethylene glycol. His temperature is 38.6°C (101.5°F), blood pressure is 88/56 mm Hg, pulse is 122/min, and respirations are 24/min. On physical examination, the patient appears lethargic and is in significant distress. The abdomen is grossly distended and tympanitic. There is marked rigidity, involuntary guarding, and rebound tenderness across all quadrants. Bowel sounds are absent. A digital rectal examination reveals an empty rectal vault. Laboratory studies show a leukocyte count of 19,200/mm³ and a serum lactate level of 4.8 mmol/L. An anteroposterior abdominal radiograph reveals a massively dilated large bowel loop resembling a "coffee bean" extending from the pelvis toward the right upper quadrant. Which of the following is the most appropriate next step in management?

A spouse brings her $45$-year-old husband to the emergency department due to profound confusion and worsening hand tremors over the past $48$ hours. The patient carries a diagnosis of bipolar disorder and has been stable on medication for years. Two weeks ago, he was prescribed lisinopril for newly diagnosed hypertension. On physical examination, his blood pressure is $112/72 \text{ mm Hg}$ and heart rate is $88 \text{ /min}$. He is somnolent, exhibits severe truncal ataxia, and demonstrates hyperreflexia in all extremities. Electrocardiography reveals a normal sinus rhythm. Given the high clinical suspicion for drug toxicity, arrange the following steps in the optimal chronological sequence for the monitoring, evaluation, and therapeutic escalation in this patient.

A 58-year-old woman is brought to the emergency department by her family after vomiting a large amount of bright red blood. The patient has a history of decompensated alcoholic cirrhosis but has not seen a physician in over a year. On arrival, she appears pale, lethargic, and diaphoretic. Temperature is 36.5°C (97.7°F), blood pressure is 82/50 mmHg, pulse is 124/min, and respiratory rate is 22/min. Oxygen saturation is 96% on room air. Physical examination reveals scleral icterus, multiple spider angiomas on the chest, and a distended abdomen with a positive fluid wave.

Two large-bore peripheral intravenous lines are placed, and rapid fluid resuscitation with crystalloid is initiated. A massive transfusion protocol is on standby. The gastroenterology team is consulted for an emergent upper endoscopy.

Which of the following pharmacologic interventions should be administered immediately in this patient? (Select all that apply.)

A 58-year-old woman is evaluated on hospital day 22 for discharge planning. She was initially admitted for severe acute necrotizing pancreatitis complicated by acute respiratory distress syndrome, requiring prolonged intubation. She eventually underwent a tracheostomy placement for failure to wean. Currently, she is hemodynamically stable and no longer requires vasopressor support. She is tolerating a tracheostomy collar for 6 hours during the day but requires continuous mechanical ventilation overnight. Her abdominal surgical wounds are open and require twice-daily complex packing with negative pressure wound therapy. She is alert, follows simple commands, and participates in physical therapy for approximately 30 minutes daily before experiencing severe fatigue. She continues to receive intravenous antibiotics for a multidrug-resistant intra-abdominal infection, which requires daily physician monitoring of her renal function and drug levels. Which of the following is the most appropriate disposition for this patient?

A 45-year-old woman is evaluated in the gastroenterology clinic for a 9-month history of severe, burning epigastric pain and chronic watery diarrhea. Her symptoms have been refractory to high-dose omeprazole therapy. An esophagogastroduodenoscopy performed three weeks ago revealed thickened gastric folds and multiple ulcerations in the duodenal bulb and the distal duodenum. The patient was instructed to discontinue her proton pump inhibitor for one week prior to today's visit, utilizing only calcium carbonate antacids for symptom relief. Vital signs are within normal limits. Physical examination reveals mild epigastric tenderness. Laboratory testing shows a fasting serum gastrin level of 640 pg/mL (Normal: < 100 pg/mL). A concurrent gastric fluid analysis demonstrates a basal gastric pH of 1.5. Which of the following is the most appropriate next step in the diagnostic workup?

A 34-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He is pale, diaphoretic, and minimally responsive. Vital signs show a temperature of 36.2°C (97.2°F), blood pressure of 72/40 mm Hg, heart rate of 135/min, and respiratory rate of 24/min. The airway is patent, and breath sounds are equal bilaterally. A focused assessment with sonography for trauma (FAST) examination is negative for intraperitoneal fluid. Pelvic examination reveals significant instability to gentle anteroposterior compression. Intravenous access is established, and a massive transfusion protocol is initiated. Which of the following are the most appropriate immediate procedural and surgical interventions for this patient? (Select all that apply)

An outpatient nephrology consultation is requested for a male patient who received a deceased-donor renal allograft four months prior. The patient reports a five-day history of persistent headaches, insomnia, and bilateral hand tremors that interfere with his ability to eat. He has also noticed a decline in his daily urine output. His maintenance immunosuppressive regimen includes tacrolimus, mycophenolate mofetil, and low-dose prednisone. Thirteen days ago, he was evaluated by an infectious disease specialist for invasive pulmonary aspergillosis, for which oral voriconazole therapy was initiated.

Vital signs today demonstrate a blood pressure of 168/98 mmHg, heart rate of 88/min, and temperature of 37.2°C (99.0°F). Physical examination reveals a fine, bilateral resting tremor in the upper extremities but is otherwise unremarkable.

Urinalysis is unremarkable with no proteinuria or cellular casts.

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

A 68-year-old woman is evaluated in the outpatient clinic for an annual preventive care visit. Her medical history includes primary hypertension, diet-controlled type 2 diabetes mellitus, and osteoarthritis of the right knee. Her current medications are amlodipine and as-needed ibuprofen. The patient is a lifetime nonsmoker and occasionally drinks wine with dinner.

Review of her preventive screening records shows a normal screening colonoscopy at age 65 and a normal bilateral mammogram 3 months ago. Bone densitometry performed at age 65 revealed a T-score of -1.1 at the lumbar spine. Recent laboratory studies show a hemoglobin A1c of 6.2% and a well-controlled lipid profile. Her vaccination history indicates she received the annual influenza vaccine recently, a Tdap booster 4 years ago, and completed the two-dose recombinant zoster vaccination series at age 65. She has never received a pneumococcal vaccination.

Vital signs today are within normal limits. Physical examination reveals crepitus in the right knee but is otherwise unremarkable.

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

A physician is called to evaluate a hospitalized patient for sudden clinical deterioration. The $53$-year-old man was admitted $14$ days ago with severe biliary pancreatitis and has been managed supportively on the medical ward. Over the past $12$ hours, he has developed high fevers, worsening abdominal pain, and confusion. Vital signs show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), heart rate of $122/\text{min}$, respiratory rate of $24/\text{min}$, and blood pressure of $88/54\text{ mmHg}$. His abdomen is diffusely tender and distended. Laboratory evaluation reveals a leukocyte count of $24,000/\text{mm}^3$. The patient is transferred to the intensive care unit, fluid resuscitation is intensified, and intravenous meropenem is started. An urgent contrast-enhanced computed tomography scan of the abdomen demonstrates a large walled-off collection replacing the body and tail of the pancreas, comprising approximately $40\%$ of the gland. There are multiple distinct pockets of gas within this collection. What is the most appropriate next step in management?

A 34-year-old man is brought to the emergency department by police due to severe agitation and aggressive behavior. He was found wandering in traffic, yelling at passing vehicles. In the emergency department, he is pacing rapidly, responding to internal stimuli, and attempting to strike staff members. He completely refuses to take any oral medications. His medical history is significant for schizophrenia, alcohol use disorder, and a recent hospital admission for an episode of syncope. Discharge records from that admission reveal a normal echocardiogram but a 12-lead ECG demonstrating sinus bradycardia with a corrected QT (QTc) interval of $540 \text{ ms}$. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $142/88 \text{ mmHg}$, heart rate $94\text{/min}$, and respiratory rate $18\text{/min}$. Which of the following is the most appropriate initial pharmacologic intervention to manage this patient's acute agitation?

A 28-year-old woman is evaluated in the outpatient gastroenterology clinic for poorly controlled, moderate-to-severe ulcerative colitis. She continues to have bloody diarrhea and abdominal cramping despite optimization of oral mesalamine and repeated courses of oral budesonide. The physician decides to initiate azathioprine as a steroid-sparing immunomodulator. In addition to a comprehensive metabolic panel for assessing baseline hepatic function, which of the following baseline diagnostic tests or ongoing monitoring parameters are essential for this patient's new pharmacotherapy? (Select 2)

A 73-year-old man is brought to the emergency department by his son due to a 3-day history of progressively worsening productive cough, subjective fevers, and confusion. The son notes that the patient has been disoriented since yesterday and has not been eating or drinking. Medical history is significant for hypertension and benign prostatic hyperplasia. On triage, his temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $86/54\text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $32/\text{min}$. Pulse oximetry shows $88\%$ on room air. On physical examination, the patient is lethargic and oriented only to person. Coarse crackles are heard over the right lower posterior lung fields. Laboratory results show a leukocyte count of $16,500/\text{mm}^3$, a blood urea nitrogen level of $34\text{ mg/dL}$, and a creatinine level of $1.5\text{ mg/dL}$. Chest radiography reveals a dense consolidation in the right lower lobe. Which of the following is the most appropriate disposition for this patient?