Pharmacologic Interventions

A 26-year-old pregnant woman, gravida 1 para 0, presents to her obstetrician at 16 weeks gestation for evaluation of a new rash. Over the past week, she has noted the appearance of non-pruritic, pink macules and papules spreading across her trunk and involving her palms and soles. She also reports mild fatigue and subjective low-grade fevers. Her first prenatal visit was two weeks ago, but she missed her scheduled laboratory testing. Her medical history is notable only for a severe anaphylactic reaction to amoxicillin during childhood, which resulted in wheezing and hospital admission. She takes a daily prenatal vitamin. Vital signs are within normal limits. Fetal heart tones are 145/min. Rapid plasma reagin testing is reactive at a titer of 1:32. A confirmatory Treponema pallidum particle agglutination test is also positive. Which of the following is the most appropriate next step in pharmacologic management?

An emergency medical services team brings a 58-year-old man to the resuscitation bay due to progressive, profound weakness and an inability to stand. The patient's husband reports that the patient missed his last two hemodialysis appointments because of a local transportation strike. The patient has a known history of end-stage renal disease secondary to hypertensive nephrosclerosis, as well as type 2 diabetes mellitus. Upon arrival, he is lethargic but arousable. Vital signs include a blood pressure of 105/65 mmHg, a heart rate of 42/min, and a respiratory rate of 16/min. An immediate 12-lead electrocardiogram demonstrates marked sinus bradycardia with absent P waves, peaked T waves, and a widened QRS complex. A point-of-care basic metabolic panel reveals a serum potassium concentration of $7.8 \text{ mEq/L}$. The clinical team consults nephrology for emergent hemodialysis but determines that temporizing pharmacologic stabilization is required immediately. Arrange the following pharmacologic interventions in the most appropriate sequential order for this patient's acute management.

A 65-year-old man presents to a primary care clinic with a 4-day history of worsening cough productive of yellow sputum, subjective fevers, and fatigue. He has a past medical history of hypertension, type 2 diabetes mellitus, and hyperlipidemia. His daily medications include lisinopril, metformin, simvastatin, and low-dose aspirin. Vital signs show a temperature of 38.2°C (100.8°F), blood pressure of 134/82 mmHg, heart rate of 92/min, and respiratory rate of 18/min. Pulse oximetry is 96% on room air. Physical examination reveals crackles in the right lower lung base. A chest radiograph demonstrates a right lower lobe infiltrate. The physician diagnoses community-acquired pneumonia. Given the patient's comorbidities, he is prescribed an outpatient oral regimen of amoxicillin-clavulanate and clarithromycin. Which of the following is the most appropriate modification to this patient's chronic medication regimen during his antibiotic therapy?

A 72-year-old woman is evaluated in the ambulatory care clinic for a routine follow-up. She has a history of type 2 diabetes mellitus, osteoarthritis, hypertension, and recurrent uncomplicated urinary tract infections. Her current medications include metformin 1000 mg twice daily, sitagliptin 100 mg daily, meloxicam 15 mg daily, nitrofurantoin 100 mg daily, and amlodipine 10 mg daily. The patient reports feeling well overall, though she mentions mild fatigue over the past few weeks. Blood pressure is 132/82 mmHg, and pulse is 76/min. Physical examination is unremarkable, with no peripheral edema.

Laboratory results from today are compared to those from six months ago:

Based on the patient's current laboratory results, which of the following medications must be entirely DISCONTINUED? (Select all that apply)

A 33-year-old woman comes to the clinic to discuss her medication regimen. She was recently diagnosed with estrogen receptor-positive breast cancer and underwent a lumpectomy with sentinel lymph node biopsy two weeks ago. Her oncologist plans to initiate adjuvant tamoxifen therapy next week. The patient has a 5-year history of major depressive disorder, which has been well controlled for the past two years with daily paroxetine. She reports that her mood is currently stable and she has no neurovegetative symptoms of depression, though she is mildly anxious about starting her new cancer treatment. She has no other medical conditions and takes no other medications. Vital signs are within normal limits. Physical examination reveals a healing surgical incision on the right breast, with no erythema or discharge. Which of the following is the most appropriate next step in the pharmacologic management of this patient's depression?

A 31-year-old man is brought to the emergency department by his partner due to severe confusion, high fever, and intractable vomiting for the past 12 hours. The partner reports that the patient was diagnosed with Graves disease two years ago but has been nonadherent to all medications for the past three months. Temperature is 40.1°C (104.2°F), pulse is 155/min, blood pressure is 162/68 mm Hg, and respirations are 26/min. Physical examination reveals a profusely diaphoretic and delirious patient. A prominent fine tremor is noted in the upper extremities. Neck examination reveals a diffusely enlarged, non-tender thyroid gland with an audible bruit. Electrocardiography demonstrates sinus tachycardia.

Arrange the following pharmacologic interventions in the strictly required chronological sequence for the acute management of this patient's condition.

A $74$-year-old man is evaluated on the inpatient medical ward. He was admitted $3$ days ago for a severe exacerbation of chronic obstructive pulmonary disease. His home medications include warfarin for permanent atrial fibrillation and a tiotropium inhaler. On admission, he was started on intravenous methylprednisolone and oral levofloxacin. Today, he reports feeling much better with decreased dyspnea and minimal cough. His vital signs are stable, with a blood pressure of $128/76$ mm Hg and a heart rate of $78$/min. Routine morning laboratory results show an International Normalized Ratio (INR) of $7.2$ (target $2.0$-$3.0$). Physical examination reveals no petechiae, ecchymoses, or signs of gastrointestinal bleeding. Which of the following is the most appropriate next step in the management of this patient's pharmacotherapy?

Emergency medical services bring a 72-year-old male resident of a skilled nursing facility to the acute care setting following a two-day history of worsening confusion, fever, and purulent sputum production. Upon triage, he appears lethargic and is in mild respiratory distress. Vital signs reveal a temperature of 38.9°C (102.0°F), a blood pressure of 88/56 mmHg, a heart rate of 112/min, and a respiratory rate of 26/min. Room air pulse oximetry indicates an oxygen saturation of 89%. Auscultation of the lungs demonstrates dense, coarse crackles localized to the right lower lung base. A portable chest radiograph confirms a new dense consolidation in the right lower lobe. A review of his electronic medical record reveals a prior ischemic stroke complicated by oropharyngeal dysphagia. Notably, he was discharged from the hospital one month ago after being treated for complicated pyelonephritis with a 10-day course of intravenous levofloxacin. Blood and sputum cultures are sent to the laboratory.

Which of the following antimicrobial agents should be included in his initial empiric pharmacologic regimen? (Select all that apply)

An internist is preparing hospital discharge orders for a $69$-year-old male who was admitted four days ago for an acute exacerbation of heart failure. The patient has a known history of ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$, type 2 diabetes mellitus, and stage 3 chronic kidney disease. Following successful intravenous diuresis, he is now euvolemic and breathing comfortably on room air.

Vital signs today show a blood pressure of $118/74$ mmHg and a heart rate of $72$/min.

Current medications planned for discharge include:
- Lisinopril $20$ mg daily
- Carvedilol $12.5$ mg twice daily
- Dapagliflozin $10$ mg daily
- Oral torsemide $20$ mg daily

To fully optimize guideline-directed medical therapy, the internist plans to prescribe spironolactone before the patient leaves the hospital.

Which of the following is the most appropriate action or instruction regarding the addition of this medication?

A 52-year-old man comes to the clinic for an urgent evaluation due to new-onset hand tremors and worsening headaches over the past three days. He underwent a deceased-donor renal transplantation eight months ago for end-stage renal disease secondary to polycystic kidney disease. His maintenance immunosuppression regimen consists of tacrolimus, mycophenolate mofetil, and low-dose prednisone. Two weeks ago, he was seen at a local urgent care clinic for a sore throat and thick, white, scrapable plaques on his tongue and buccal mucosa. He was prescribed a 14-day course of an oral medication for this condition. Today, his temperature is 37.1°C (98.8°F), blood pressure is 158/92 mm Hg, and pulse is 88/min. Physical examination is notable for a fine resting tremor in both hands. Laboratory studies reveal a serum creatinine of 2.4 mg/dL, which is significantly elevated from his baseline of 1.3 mg/dL measured one month ago. Which of the following medications was most likely prescribed at the urgent care clinic?

Paramedics bring a 58-year-old woman to the emergency department after her husband witnessed her suddenly collapse and begin shaking. Upon arrival in the resuscitation bay, she is actively experiencing a generalized tonic-clonic seizure. Her husband states the seizure activity has been continuous for approximately 15 minutes without any return to consciousness. She has no known past medical history and takes no daily medications. Vital signs show a blood pressure of 145/90 mmHg, heart rate of 118/min, and oxygen saturation of 94% on a non-rebreather mask. Intravenous access is rapidly established by the nursing staff, and a point-of-care blood glucose level is 102 mg/dL.

Arrange the following pharmacologic interventions in the correct sequential order for the management of this patient's condition, starting from the most immediate initial therapy to the final step for super-refractory disease.

A 78-year-old female patient is evaluated during a routine ambulatory appointment at a geriatrics clinic. Her daughter, who provides collateral history, expresses concern regarding the patient's escalating confusion and recent onset of urinary dribbling over the past month. The patient's medical history includes major depressive disorder, essential hypertension, type 2 diabetes mellitus, and painful diabetic peripheral neuropathy. Her daily medication regimen consists of metformin, amlodipine, sertraline, amitriptyline (initiated four weeks ago for neuropathy), and over-the-counter diphenhydramine (taken nightly for insomnia).

Vital signs show a heart rate of 92/min. Blood pressure is 138/82 mm Hg while supine and 112/68 mm Hg upon standing. Physical examination is notable for dry oral mucous membranes, delayed capillary refill, and a mildly distended, palpable mass in the suprapubic region. A bedside ultrasound of the bladder demonstrates a postvoid residual volume of 550 mL.

Which of the following is the most appropriate initial pharmacologic intervention?

A 58-year-old man is brought to the emergency department by his wife due to fever, severe headache, and confusion that started 12 hours ago. He has a past medical history of alcohol use disorder, type 2 diabetes mellitus, and hypertension. His temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and heart rate is 115/min. On physical examination, he is lethargic but arousable. There is significant resistance to passive neck flexion. Funduscopic examination shows no papilledema. Lumbar puncture is performed, and cerebrospinal fluid (CSF) analysis reveals a leukocyte count of 2,400/mm³ (90% neutrophils), a glucose level of 30 mg/dL, and a protein level of 150 mg/dL. Gram stain of the CSF is pending.

Which of the following pharmacologic agents should be included in his immediate empiric regimen? (Select all that apply)

A 68-year-old man is evaluated in the urgent care clinic for a 24-hour history of severe, progressive pain and swelling in his right knee. He is unable to bear weight on the affected leg. His medical history is significant for type 2 diabetes mellitus, hypertension, and stage 4 chronic kidney disease with a baseline estimated glomerular filtration rate (eGFR) of $24 \text{ mL/min/1.73 m}^2$. Current medications include amlodipine, insulin detemir, and calcium acetate. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse 88/min, and blood pressure 138/84 mm Hg. Physical examination reveals a swollen, erythematous, and exquisitely tender right knee with a moderate effusion. Arthrocentesis is performed. Synovial fluid analysis reveals a leukocyte count of $28,000/\mu\text{L}$ (85% neutrophils) and the presence of negatively birefringent, needle-shaped crystals under polarized light microscopy. Gram stain is negative. Which of the following is the most appropriate pharmacologic intervention for this patient's acute joint condition?

A 58-year-old man is evaluated in the hospital for a 5-day history of fever, nonproductive cough, and right-sided pleuritic chest pain. He underwent a deceased-donor renal transplantation eight months ago and is maintained on a daily immunosuppressive regimen of tacrolimus, mycophenolate mofetil, and low-dose prednisone. Vital signs are temperature $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse $108/\text{min}$, respirations $20/\text{min}$, and blood pressure $138/82\text{ mm Hg}$. Chest computed tomography reveals a dense right upper lobe nodule with a surrounding halo of ground-glass attenuation. Serum galactomannan assay is strongly positive, and bronchoscopy with bronchoalveolar lavage confirms the diagnosis of invasive pulmonary aspergillosis. The medical team decides to initiate the standard first-line targeted intravenous antifungal therapy for this condition. Which of the following concurrent pharmacologic interventions is most appropriate for this patient?

Evaluation is underway for a patient hospitalized on the medical ward who is recovering from an exacerbation of chronic obstructive pulmonary disease. The patient, who has a past medical history of heart failure with preserved ejection fraction, paroxysmal atrial fibrillation, and major depressive disorder, was initially treated with intravenous methylprednisolone and continuous nebulized albuterol. His symptoms have significantly improved, and he is now breathing comfortably on room air.

His home medications, which were continued during the admission, include diltiazem, apixaban, escitalopram, and atorvastatin. Morning laboratory results are notable for a serum potassium level of $3.1 \text{ mEq/L}$ and a serum magnesium level of $1.6 \text{ mg/dL}$. A routine 12-lead electrocardiogram performed today shows normal sinus rhythm with a QTc interval of $530 \text{ milliseconds}$. Before the planned discharge, a sputum polymerase chain reaction panel returns positive for Mycoplasma pneumoniae, prompting the decision to initiate targeted oral antibiotic therapy.

Which of the following is the most appropriate antimicrobial regimen to prescribe for this patient?

A 62-year-old man is brought to the emergency department by emergency medical services (EMS) due to the sudden onset of difficulty breathing, facial swelling, and a diffuse pruritic rash. The symptoms began 15 minutes ago while he was eating at a seafood restaurant. His medical history is significant for hypertension, coronary artery disease, and heart failure with preserved ejection fraction. His home medications include lisinopril, metoprolol, aspirin, and atorvastatin. Upon arrival, his blood pressure is 74/40 mm Hg, pulse is 62/min, and oxygen saturation is 90% on room air. Physical examination reveals marked angioedema of the lips, widespread urticaria, and diffuse bilateral expiratory wheezing. EMS has established peripheral intravenous access.

Arrange the following pharmacologic interventions in the correct sequential order of administration for the acute escalation of therapy in this patient.

A 62-year-old woman is evaluated in the emergency department for right lower extremity swelling and pain that began 2 days ago. Her past medical history is significant for hypertension, type 2 diabetes mellitus, and end-stage renal disease requiring hemodialysis three times a week. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 142/86 mmHg, pulse of 88/min, and respiratory rate of 14/min. Physical examination reveals a swollen, tender, and erythematous right calf. A comprehensive metabolic panel is notable for a blood urea nitrogen of 42 mg/dL and a serum creatinine of 5.8 mg/dL. Compression ultrasonography of the right lower extremity demonstrates a noncompressible right popliteal vein. Which of the following is the most appropriate initial pharmacologic intervention for this patient?

A 56-year-old man is brought to the emergency department by ambulance after vomiting a large amount of bright red blood. He has a history of alcohol use disorder and compensated cirrhosis. On arrival, he is lethargic but localizes to pain and maintains his airway. Blood pressure is 88/55 mm Hg, and pulse is 118/min. Physical examination reveals scleral icterus, palmar erythema, and a distended abdomen with shifting dullness. Two large-bore peripheral intravenous lines are placed, and fluid resuscitation with isotonic crystalloid is initiated. Laboratory studies show:

Which of the following pharmacologic interventions are most appropriate for this patient at this time? (Select all that apply)

A 68-year-old male with a history of type 2 diabetes mellitus is admitted to the intensive care unit due to severe community-acquired pneumonia and worsening hypotension. His weight is 80 kg. Upon arrival, his blood pressure is 75/40 mm Hg, heart rate is 128/min, and respiratory rate is 28/min. Initial laboratory results demonstrate a serum lactate of 5.2 mmol/L. Appropriate empiric broad-spectrum antibiotics have already been administered. Arrange the following pharmacologic interventions in the correct sequential order of escalation for managing this patient's hemodynamics, assuming he remains persistently hypotensive after each preceding step is fully implemented.