An asymptomatic 48-year-old Caucasian female with a history of hypothyroidism is being evaluated for abnormal liver function tests.  She has no other medical problems.  She takes thyroxine for the hypothyroidism.  She takes no herbal medication.  She never smoked or used IV drugs, and rarely drinks alcohol.  Her family history is unremarkable.  Her blood pressure is 120/80 mmHg, pulse is 72/min, temperature is 36.7C (98F) and respirations are 14/min.  The physical examination is normal, except for mild, painless hepatomegaly.  The initial lab test results are as follows:

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

A 74-year-old woman is brought to the emergency department with fever, chills, and shortness of breath.  Two days ago, the patient choked while having tea and doughnuts and almost lost consciousness.  Her son performed the Heimlich maneuver.  The patient has advanced Alzheimer disease, and her son is her health care proxy and primary caregiver; her 73-year-old husband also participates in her care.  Medical history includes hypertension, hyperlipidemia, coronary artery disease, ischemic stroke with mild residual right hemiparesis, and urinary incontinence.  Temperature is 38.9 C (102 F), blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 18/min.  Pulse oximetry shows 89% oxygen saturation on room air and 94% on 2 liters by nasal canula.  On auscultation of the chest, crackles are noted at the right lung base.  Heart sounds are regular.  There is no jugular venous distension.  The abdomen is soft, nontender, and nondistended.  There is no peripheral edema.  Laboratory results are as follows:

Portable chest x-ray reveals a right lower lobe infiltrate.

Item 1 of 4

Which of the following is the most appropriate antibiotic choice for this patient?

Item 2 of 4

During the night, the patient has several episodes of hypotension.  Aggressive intravenous fluid therapy is initiated, and a Foley catheter is placed.  Her blood pressure normalizes.  Over the next 12 hours, the patient’s urine output drops to 5 mL/hr.  Despite receiving intravenous fluids, the patient’s urine output remains low on the fourth day of hospitalization.  Temperature is 37.3 C (99.1 F), blood pressure is 122/70 mm Hg, and pulse is 78/min.  Laboratory results are as follows:

Further evaluation of this patient would most likely show which of the following?

Item 3 of 4

During the past 4 days of hospitalization, the patient has received 6 L of intravenous fluids.  Her urine output has been 400 mL over the past 24 hours.  She has been afebrile for the past 2 days.  Blood cultures are negative.  The patient is currently receiving 150 mL/hr of lactated Ringer solution.  Temperature is 36.7 C (98 F), blood pressure is 140/70 mm Hg, pulse is 82/min, and respirations are 18/min.  Oxygen saturation is 96% on 2 L of O₂ by nasal cannula.  The mucous membranes are moist.  The right basal crackles are unchanged, but there are no other abnormal lung sounds.  There is no pericardial rub, peripheral edema, or asterixis.  A basic metabolic panel is ordered.  Laboratory results are as follows:

ECG shows no abnormal intervals and no peaked T waves.  Which of the following is the most appropriate course of action at this time?

Item 4 of 4

With appropriate treatment, the patient recovers kidney function.  She is afebrile with a mild, persistent cough.  Which of the following actions is most important prior to discharging this patient?

You are the current “on call physician” for your group, when you receive a call regarding one of your nursing home patients. The nurse reports that one patient has been acting strangely for the last few hours and is agitated at times.  This patient is an 82-year-old female who has been in the nursing home for the last two years, and has always been very pleasant. You know her very well from your recent nursing home visit. She has a past medical history of hypertension, diabetes mellitus, osteoporosis, and Alzheimer’s dementia. Her daily medications are amlodipine, metformin, calcium – vitamin D, and donepezil. You are concerned that something is not right with the patient.

Item 1 of 3

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

Item 2 of 3

The nurse calls you back in twenty minutes.  She states that she gave a dose of prn (as needed) medication which was ordered by a physician before.  She arranged an ambulance to transfer the patient to a nearby hospital.  Her temperature is 36.7 C (98 F), blood pressure is 116/78 mmHg, pulse rate is 76/min, and respiratory rate is 18/min.  She is still agitated, and she is now disoriented to place and person.  She gets easily distracted, and she is having auditory hallucinations.  In the hospital, her physical examination is unremarkable.  What is the most appropriate next step in the management of her condition?

Item 3 of 3

A CT scan of the patient’s head is normal. Initial lab studies reveal the presence of a urinary tract infection with mild prerenal azotemia. You start the patient on empiric antibiotic therapy and intravenous fluids; however, the patient’s mental status remains unchanged. You provide a bedside sitter for the patient for constant supervision. The sitter reports that the patient is very combative now. She has been trying to get out of bed and has twice attempted to pull her IV line out. She resisted the physical restraints that the nurse was trying to apply. Frequent orientation and reassurance has not improved her behavior. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old man is hospitalized for an elective coronary artery bypass graft surgery.  The patient has been having exertional chest pain and was found to have a left main coronary artery disease.  Other medical issues include hypertension, hyperlipidemia, and stage 3 chronic kidney disease.  The patient is a retired financial advisor with a 50-pack-year smoking history.  He undergoes the surgery without operative complications and is successfully extubated the next day.  Postoperative medications include atorvastatin, metoprolol, and morphine.  On the third postoperative day, the patient is found to be progressively drowsy, lethargic, and difficult to rouse.  Temperature is 36.1 C (97 F), blood pressure is 110/68 mm Hg, pulse is 112/min and irregular, and respirations are 9/min and shallow.  Examination shows flat neck veins and mild bibasilar lung crackles.  Pupils are 1 mm and equal.  The patient withdraws all extremities equally to pain.  ECG shows atrial fibrillation with rapid ventricular response.  Fingerstick glucose level is 125 mg/dL.  Laboratory results are as follows:

The laboratory findings are not significantly changed compared to preadmission values.  Which of the following is the most appropriate next step in management of this patient’s altered mental status?

A 76-year-old female is seen in the clinic with numerous medical complaints.  She is scheduled to undergo elective surgery for right hip replacement.  She says she is tired, has a very poor appetite, and does not sleep well at night.  She denies any fevers, chills, chest pain, or shortness of breath.  Her ECG and chest x-ray are normal.  She cannot remember which medications she takes.  What is the most important factor in perioperative adverse drug reaction in the elderly population?

A 57-year-old woman comes to the office at the insistence of her husband; he reports that for quite some time she has been extremely agitated when sitting, resting, or lying down at night.  The patient has trouble falling asleep in bed, which in turn keeps her husband awake.  She says the discomfort occurs every night and describes it as an “internal itch that creeps up my lower legs and sometimes is so uncomfortable I could cry.”  The sensation compels her to stand and pace the floor and worsens when she feels fatigued.  Medical history is significant for well-controlled hypertension, gastroesophageal reflux disease, allergic rhinitis, and tension headaches.  The patient has been taking amlodipine, omeprazole, and ibuprofen for 3 years with no recent changes in dosage.  She does not smoke or use recreational drugs but consumes 1-2 alcoholic drinks on weekends.  There is no family history of similar symptoms.  Physical examination is unremarkable.

Item 1 of 2

Which of the following is the most appropriate test to order?

Item 2 of 2

The appropriate study was ordered, and the results are within normal limits.  Which of the following medications should be prescribed at this time?

A 78-year-old man is brought to the emergency department due to a few days of hallucinations, delusions, and aggressive behavior, according to his nephew.  He has not had any fever, chills, decreased vision, headaches, abdominal pain, or weight loss.  Other medical problems include hypertension, coronary artery disease, and osteoporosis.  The patient does not use tobacco or alcohol.  He lives alone and follows a strict vegan diet.  Temperature is 37.2 C (99 F), blood pressure is 141/88 mm Hg, pulse is 96/min, and respirations are 14/min.  Examination shows dry mucous membranes.  The abdomen is soft, nontender, and nondistended, with no rebound tenderness or rigidity.  The range of motion of the spine is normal and without pain, scoliosis, excessive kyphosis, or tenderness to palpation of the lower back.  Mental status examination reveals an agitated, elderly man with delusional ideation and bizarre behavior.  There are no motor or sensory focal deficits, and no meningeal signs.  Laboratory results are as follows:

Chest-x ray and urinalysis results are normal.  Which of the following is the most appropriate pharmacotherapy?