All practice questions

A $62$-year-old man is evaluated on postoperative day $5$ following an elective anterior resection of the rectum for a malignant mass. Over the past $6$ hours, he has developed progressively worsening, severe abdominal pain and altered mental status. His medical history is significant for type 2 diabetes mellitus and hypertension. His current temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $86/52\text{ mm Hg}$, pulse is $128/\text{min}$, and respiratory rate is $26/\text{min}$. Physical examination reveals an ill-appearing, diaphoretic patient. The abdomen is distended, tense, and diffusely tender to palpation with involuntary guarding and pronounced rebound tenderness. Bowel sounds are absent. The surgical incision shows no signs of erythema or purulent discharge. Laboratory studies demonstrate a leukocyte count of $19,400/\text{mm}^3$ with $14\%$ band forms, and a serum lactate level of $4.2\text{ mmol/L}$. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated immediately. Which of the following is the most appropriate next step in management?

A 28-year-old primigravida at 39 weeks gestation is admitted to the labor and delivery unit for induction of labor. The attending physician enters an order for continuous intravenous oxytocin. Recently, the hospital implemented a major software update to its electronic health record (EHR) and medication dispensing systems. While initiating the infusion, the bedside nurse misinterprets a new drop-down menu on the interface and inadvertently programs the smart pump to deliver ten times the ordered dose. Thirty minutes later, continuous fetal monitoring reveals severe uterine tachysystole accompanied by recurrent late decelerations. The charge nurse immediately identifies the infusion error, stops the oxytocin, and administers subcutaneous terbutaline. The fetal heart rate tracing normalizes shortly after, and a healthy infant is delivered vaginally four hours later. Which of the following is the most appropriate next step for the hospital leadership regarding this event?

A surgical rapid response is called for a patient experiencing acute deterioration on the surgical ward. The patient, a $68$-year-old male, underwent an uncomplicated laparoscopic repair of a large type III paraesophageal hernia $48$ hours ago. His medical history is significant for hypertension, type $2$ diabetes mellitus, and polymyalgia rheumatica. He has been taking amlodipine, metformin, and prednisone ($15$ mg daily) for the past year. Due to severe postoperative nausea and emesis, he has been strictly nil per os (NPO) since the surgery and has only received intravenous lactated Ringer solution and prochlorperazine. Currently, he appears lethargic. Vital signs reveal a temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), heart rate of $128$/min, respiratory rate of $22$/min, and blood pressure of $78/48$ mmHg. Physical examination shows dry mucous membranes and a non-distended, soft, and non-tender abdomen. His surgical port sites are clean without erythema. An electrocardiogram demonstrates sinus tachycardia. Laboratory studies are returned as follows:

* Sodium: $126$ mEq/L
* Potassium: $5.6$ mEq/L
* Chloride: $94$ mEq/L
* Bicarbonate: $18$ mEq/L
* Blood urea nitrogen: $32$ mg/dL
* Creatinine: $1.4$ mg/dL
* Glucose: $52$ mg/dL

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

A 54-year-old man presents to the clinic reporting a 4-month history of persistent fatigue, sluggishness, and increased sensitivity to cold. He also mentions a recent decline in his sexual drive and difficulty maintaining an erection. He has no past medical history and takes no medications. His temperature is $36.2^{\circ}\text{C}$ ($97.2^{\circ}\text{F}$), blood pressure is $108/68\text{ mm Hg}$, and pulse is $55\text{/min}$. Physical examination demonstrates pale, dry skin and a noticeable delay in the relaxation phase of the patellar reflexes. Confrontational visual field testing detects a deficit in the temporal fields bilaterally.

Laboratory results are as follows:
Thyroid-stimulating hormone (TSH): $1.8\text{ }\mu\text{IU/mL}$ (normal: $0.4-4.0\text{ }\mu\text{IU/mL}$)
Free thyroxine (T4): $0.5\text{ ng/dL}$ (normal: $0.9-1.7\text{ ng/dL}$)
Total testosterone: $140\text{ ng/dL}$ (normal: $300-1,000\text{ ng/dL}$)

Which of the following is the most likely underlying mechanism for this patient's findings?

A 72-year-old man is brought to the emergency department from a long-term care facility due to a 4-day history of profuse, watery diarrhea and progressive lethargy. His medical history includes hypertension, benign prostatic hyperplasia, and moderate chronic obstructive pulmonary disease. His medications include amlodipine, tamsulosin, and an albuterol inhaler as needed. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is 98/62 mm Hg, pulse is 114/min, and respirations are 24/min. Physical examination shows dry mucous membranes, delayed capillary refill, and decreased skin turgor. Lungs are clear to auscultation bilaterally.

Which of the following best describes this patient's acid-base status?

During a collegiate rugby match, an 18-year-old athlete sustains a high-impact direct blow to the anterior right proximal tibia while the foot is firmly planted on the turf. The athlete falls to the ground in severe distress and is unable to bear weight. On examination in the emergency department 45 minutes later, there is a prominent step-off at the right knee joint, with the tibia displaced posteriorly relative to the femur. The overlying skin is intact. The patient reports severe pain but denies any numbness or tingling in the foot. Dorsalis pedis and posterior tibial pulses are palpable and symmetric to the uninjured leg. Capillary refill is less than 2 seconds. A bedside closed reduction is performed promptly under conscious sedation, successfully restoring normal anatomic alignment of the knee. Post-reduction, the distal pulses remain palpable and symmetric. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation with the most appropriate procedural or operative intervention.

Emergency medical services bring a 67-year-old man to the hospital due to profound lethargy and reduced urine output over the last 24 hours. His medical history includes severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy. A legally binding advance directive in his electronic medical record designates his wife as his healthcare proxy; she has previously consented to all life-saving interventions. Currently, his son is at the bedside and explicitly demands that no breathing tubes be placed. Vital signs reveal a temperature of 38.9°C (102.0°F), blood pressure of 82/45 mm Hg, pulse of 126/min, and respirations of 32/min. Physical examination shows a somnolent patient who only localizes to painful stimuli. Jugular venous pressure is 5 cm H₂O. Lung auscultation demonstrates diminished breath sounds bilaterally with shallow inspiratory efforts. The patient receives 3 liters of intravenous crystalloids, broad-spectrum antibiotics, and a norepinephrine infusion. A brief accidental disconnection of his oxygen tubing by a staff member is noted and immediately corrected. Arterial blood gas analysis on room air shows:

pH: $7.23$
PaCO₂: $35 \text{ mm Hg}$
PaO₂: $72 \text{ mm Hg}$
HCO₃⁻: $14 \text{ mEq/L}$

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

A 62-year-old man undergoes an uncomplicated elective laparoscopic cholecystectomy. On postoperative day 1, his temperature rises to 38.5°C (101.3°F). His vital signs are otherwise stable, and physical examination reveals clear lungs, normal bowel sounds, and mild tenderness at the incision sites without erythema. The cross-covering resident physician immediately orders a comprehensive infectious workup, including blood and urine cultures, and initiates empiric broad-spectrum intravenous antibiotics with vancomycin and piperacillin-tazobactam. Shortly after the first infusion begins, the patient suffers a severe anaphylactic reaction requiring emergency intubation and transfer to the intensive care unit. The hospital's quality and safety committee conducts a Root Cause Analysis (RCA) of this adverse event. Based on principles of patient safety and quality improvement, which of the following is the most appropriate conclusion and corresponding systemic action?

A 65-year-old man is brought to the emergency department by his family due to a 2-day history of worsening shortness of breath and an increase in the volume and purulence of his sputum. His medical history includes chronic obstructive pulmonary disease and mild heart failure with preserved ejection fraction. Vital signs show a temperature of 37.4°C (99.3°F), blood pressure of 138/86 mm Hg, heart rate of 108/min, respiratory rate of 24/min, and oxygen saturation of 89% on room air. Physical examination reveals a prolonged expiratory phase with diffuse expiratory wheezing bilaterally. There is no jugular venous distention, and no lower extremity edema is appreciated. A chest radiograph demonstrates hyperinflated lung fields and flattened diaphragms without focal consolidations or pleural effusions. An arterial blood gas analysis on room air shows a pH of 7.32, PaCO2 of 54 mm Hg, and PaO2 of 58 mm Hg. Which of the following are appropriate initial management steps for this patient? (Select all that apply)

A 65-year-old woman is evaluated in the emergency department due to a two-day history of progressively worsening shortness of breath, a cough productive of yellow sputum, and a sensation of a racing heartbeat. Her medical history includes chronic obstructive pulmonary disease (COPD) and essential hypertension. Her daily home medications include an inhaled long-acting muscarinic antagonist and a low-dose thiazide diuretic. Vital signs show a temperature of 37.5°C (99.5°F), blood pressure of 132/84 mmHg, pulse of 128/min, and respiratory rate of 24/min. Pulse oximetry on room air is 88%. Physical examination reveals a prolonged expiratory phase with diffuse bilateral expiratory wheezing, but no inspiratory crackles. The jugular venous pressure is 8 cm H2O. Cardiac auscultation reveals an irregularly irregular rhythm with a loud P2, but no S3 gallop or murmurs are appreciated. Trace bilateral lower extremity edema is present. An electrocardiogram demonstrates a narrow QRS complex tachycardia with an irregular R-R interval, varying PR intervals, and three distinct P-wave morphologies in lead II. Which of the following is the most appropriate initial management for this patient's condition?

A 64-year-old man is brought to the emergency department via ambulance due to the sudden onset of severe, "tearing" chest pain that radiates to his interscapular region. He has a history of poorly controlled hypertension. On arrival, he appears diaphoretic and in severe distress. Blood pressure is 210/115 mm Hg in the right arm and 160/90 mm Hg in the left arm, with a heart rate of 112/min. Physical examination reveals a new early diastolic decrescendo murmur heard best at the right upper sternal border. An electrocardiogram shows sinus tachycardia with left ventricular hypertrophy, but no acute ischemic changes. A portable chest radiograph reveals a widened mediastinum. Intravenous access and continuous hemodynamic monitoring have been established.

Arrange the following management steps in the most appropriate sequential order for this patient's acute presentation.

A 59-year-old man with a known history of alcohol-related cirrhosis is brought to the emergency department by his family due to increasing confusion, lethargy, and diffuse abdominal discomfort over the past $48$ hours. His home medications include nadolol, spironolactone, and furosemide. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), pulse is $92/\text{min}$, blood pressure is $105/65\text{ mmHg}$, and respirations are $16/\text{min}$. Physical examination reveals scleral icterus and spider angiomas. The abdomen is distended with shifting dullness and diffuse, mild tenderness to palpation without rebound or guarding. Asterixis is present on neurologic examination.

A diagnostic paracentesis is performed, and ascitic fluid analysis reveals a total protein of $1.1\text{ g/dL}$ and a leukocyte count of $650/\text{mm}^3$ with $75\%$ neutrophils.

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

Match each Hepatitis B (HBV) serologic and virologic profile to its corresponding clinical disease state.

A 42-year-old man presents to the emergency department with a 4-week history of productive cough, low-grade fever, drenching night sweats, and a 5-kg (11-lb) weight loss. He emigrated from a country with a high incidence of tuberculosis two years ago. Vital signs show a temperature of 38.1°C (100.6°F), heart rate of 92/min, blood pressure of 120/78 mm Hg, respiratory rate of 18/min, and oxygen saturation of 97% on room air. Physical examination reveals bronchial breath sounds and crackles in the right upper lung field. He is currently waiting in the general triage area. Arrange the following management steps in the most appropriate chronological order.

A 42-year-old woman comes to the clinic reporting a 5-month history of worsening fatigue, a $4\text{ kg}$ ($8.8\text{ lb}$) weight gain, and generalized weakness. She also notes that her menstrual periods have been absent for the past 6 months. Her last menstrual period was 7 months ago, and prior to this, her cycles were regular. She has no prior medical history and takes no medications. Vital signs show a pulse of $54 \text{ /min}$ and blood pressure of $100/60 \text{ mmHg}$. Physical examination reveals pale, dry skin and delayed relaxation of the deep tendon reflexes. Visual field testing by confrontation is normal.

Laboratory studies show the following:

Which of the following is the most likely explanation for this patient's clinical and laboratory findings?

Match each clinical presentation of a lower genital tract infection with the most appropriate corresponding microscopic or diagnostic laboratory finding.

Progressive respiratory distress and a persistent nighttime cough prompt a $68$-year-old woman to seek medical evaluation at a local urgent care clinic. She states that over the past $4$ days, she has been unable to sleep lying flat and has needed to prop herself up with three pillows. Her medical history includes hypertension, type 2 diabetes mellitus, a myocardial infarction three years prior, and a $30$-pack-year smoking history. She currently uses an as-needed albuterol inhaler. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $156/94 \text{ mm Hg}$, heart rate of $110/\text{min}$, and respiratory rate of $26/\text{min}$. Pulse oximetry reveals an oxygen saturation of $91\%$ on room air. Physical examination demonstrates prominent jugular venous distention when the patient is seated at a $45^\circ$ angle. Auscultation of the lungs reveals diffuse expiratory wheezes bilaterally and dullness to percussion at the bases. Cardiac auscultation identifies a regular tachycardia and a third heart sound (S3) gallop. A point-of-care arterial blood gas demonstrates a pH of $7.48$, $\text{PaCO}_2$ of $30 \text{ mm Hg}$, and $\text{PaO}_2$ of $64 \text{ mm Hg}$. Which of the following is the most appropriate initial step in management for this patient?

A $68$-year-old man is evaluated on postoperative day $5$ following a partial colectomy for recurrent uncomplicated diverticulitis. Over the past $24$ hours, he has developed a fever, tachycardia, and new-onset copious, watery diarrhea. He reports mild, diffuse abdominal cramping but no nausea or vomiting. His current medications include intravenous fluids, prophylactic subcutaneous enoxaparin, and patient-controlled analgesia. He received a standard course of perioperative intravenous cefoxitin. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $118/74 \text{ mm Hg}$, and pulse is $112/\text{min}$. On physical examination, the abdomen is mildly distended and diffusely tender to deep palpation, without rigidity or rebound tenderness. The surgical incision is clean, dry, and intact.

Laboratory studies show:
Leukocyte count: $18,500/\text{mm}^3$

Arterial blood gas (room air):
pH: $7.32$
pCO $_2$: $30 \text{ mm Hg}$
HCO $_3^-$: $15 \text{ mEq/L}$

A stool enzyme immunoassay (EIA) is positive for *Clostridioides difficile* toxins A and B.

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

An intensive care unit team is reviewing pulmonary artery catheterization data for several critically ill patients. Match each patient's clinical presentation with their expected central hemodynamic profile. (Note: Arrows indicate relative changes: $\uparrow$ increased, $\downarrow$ decreased, $\leftrightarrow$ normal or unchanged).