All practice questions

During morning multidisciplinary rounds in the intensive care unit, the team evaluates a 73-year-old male who has been mechanically ventilated for the past $48$ hours. His initial presentation involved profound hypoxemia due to community-acquired pneumonia. The patient's medical history includes ischemic cardiomyopathy (left ventricular ejection fraction of $25\%$) and severe emphysema.

He was empirically started on intravenous vancomycin and piperacillin-tazobactam. The microbiology laboratory has just finalized the results of blood and bronchoalveolar lavage fluid cultures obtained at admission; both demonstrate heavy growth of *Streptococcus pneumoniae*. The susceptibility report confirms the isolate is sensitive to all tested antibiotics, including ceftriaxone and penicillin.

Vital signs reveal a heart rate of $112$/min and a blood pressure of $118/72$ mm Hg. He is afebrile. Physical examination shows engorged neck veins when the head of the bed is elevated. Cardiac auscultation identifies a third heart sound (S3). Lung examination yields diffuse bilateral crepitations that extend to the mid-apices, accompanied by prolonged expiratory wheezing.

An arterial blood gas analysis on current ventilator settings reveals:
- pH: $7.18$
- pCO $_2$: $56$ mm Hg
- pO $_2$: $82$ mm Hg
- HCO $_3^-$: $20$ mEq/L

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

A 27-year-old woman, G1P0, at 7 weeks gestation presents to the clinic for her first prenatal visit. She reports mild morning nausea and breast tenderness but otherwise feels well. She was diagnosed with primary hypothyroidism secondary to Hashimoto thyroiditis 4 years ago and has been taking levothyroxine $100 \mu\text{g}$ daily since that time. Her pre-pregnancy thyroid function tests were consistently within normal limits. Her vital signs are stable, and physical examination shows a normal-sized, non-tender thyroid gland without nodules.

Laboratory evaluation reveals the following:

Which of the following is the most appropriate next step in the management of this patient's thyroid condition?

Match each clinical presentation of genital ulcer disease to the most appropriate first-line pharmacotherapy.

Correlate the following specific jugular venous pulse (JVP) waveform abnormalities with the underlying cardiovascular pathology that most classically produces them.

A 29-year-old woman comes to the clinic reporting a bothersome, malodorous vaginal discharge for the past week. She describes the odor as "fishy" and notes that it becomes more pronounced after unprotected sexual intercourse. She has a new male sexual partner. The patient denies any vulvar itching, burning, dysuria, or lower abdominal pain. Her medical history is unremarkable, and she takes no medications. Vital signs are within normal limits. Pelvic examination reveals a thin, homogeneous, grayish-white discharge evenly coating the vaginal walls. There is no vulvovaginal erythema, cervical motion tenderness, or adnexal tenderness. The vaginal fluid pH is 5.5. Addition of 10% potassium hydroxide to the vaginal discharge produces a strong amine odor. Microscopic evaluation of a wet mount preparation reveals squamous epithelial cells whose borders are obscured by adherent coccobacilli. Which of the following is the most appropriate next step in management?

Match the following clinical vignettes describing postoperative complications in pediatric cardiac surgery patients with their corresponding underlying pathophysiologic mechanism.

Match each clinical presentation during a prenatal visit to the most appropriate next step in management or indicated evaluation.

A series of afebrile patients with stable vital signs present to the gynecology clinic evaluating for abnormal vaginal discharge and discomfort. Match each patient's specific clinical context and diagnostic findings with the most accurate diagnosis and its corresponding guideline-concordant management.

A 65-year-old woman is evaluated in the hospital on postoperative day 2 following an elective total right knee arthroplasty due to sudden-onset palpitations, severe shortness of breath, and lightheadedness. Her medical history includes hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. Her temperature is 37.9°C (100.2°F), blood pressure is 82/50 mm Hg, heart rate is 148/min, and respiratory rate is 26/min. Pulse oximetry is 91% on 2 L/min of oxygen via nasal cannula. On physical examination, the patient appears distressed and diaphoretic. Her extremities are cool to the touch with delayed capillary refill. Jugular venous distension is present. Lung auscultation reveals bibasilar crackles and scattered expiratory wheezes. Cardiac examination shows an irregularly irregular rhythm with a rapid rate and no distinct murmurs. The right knee surgical site is intact with expected mild swelling and no purulent drainage. An electrocardiogram demonstrates an irregularly irregular rhythm with narrow QRS complexes and absent P waves. Which of the following is the most appropriate immediate next step in management?

An 82-year-old woman residing in a skilled nursing facility is evaluated during a routine monthly check-up. Her medical history includes Alzheimer dementia, hypertension, and type 2 diabetes mellitus. The facility staff requested a urinalysis today because they noted her urine has appeared cloudy and malodorous over the past three days. The patient has no complaints and denies any pain. Temperature is 37.0°C (98.6°F), blood pressure is 138/82 mm Hg, pulse is 76/min, and respirations are 14/min. The patient is alert, pleasant, and oriented to her own name, which is consistent with her baseline mental status. Abdominal examination reveals a soft, non-distended abdomen with no suprapubic or costovertebral angle tenderness. A clean-catch urinalysis shows a specific gravity of 1.015, pH 6.5, positive leukocyte esterase, positive nitrites, and 45 white blood cells/hpf. Which of the following is the most appropriate next step in management?

A 52-year-old man is brought to the emergency department by his wife due to a 24-hour history of high fever, severe generalized headache, and progressive confusion. On physical examination, his temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, heart rate is 115/min, and respiratory rate is 18/min. He is lethargic but arousable. Neurologic examination reveals marked nuchal rigidity and a new, mild right-sided hemiparesis. Fundoscopic examination shows early papilledema. The physician suspects acute bacterial meningitis. Arrange the following steps in the most appropriate chronological order for the initial management of this patient.

Match each patient's clinical presentation and response to dynamic auscultatory maneuvers with the corresponding underlying hemodynamic mechanism.

During bedside rounds on the medical-surgical ward, a clinical team evaluates a patient on hospital day $4$. The patient was initially admitted for severe acute pancreatitis secondary to cholelithiasis. Despite adequate initial volume resuscitation, the patient has required continuous nasojejunal enteral nutrition and aggressive pain management for unremitting epigastric discomfort.

Vital signs demonstrate a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), a heart rate of $112\text{/min}$, respirations of $18\text{/min}$, and a blood pressure of $116/72\text{ mm Hg}$.

Physical examination reveals a distended abdomen with marked epigastric tenderness. Bowel sounds are hypoactive. No scleral icterus is present.

Laboratory analysis shows:
Leukocyte count: $15,800\text{/mm}^3$
Hemoglobin: $14.2\text{ g/dL}$
Blood urea nitrogen: $28\text{ mg/dL}$
Total bilirubin: $0.9\text{ mg/dL}$ (decreased from $3.2\text{ mg/dL}$ on admission)
Alkaline phosphatase: $110\text{ U/L}$ (decreased from $340\text{ U/L}$ on admission)
Alanine aminotransferase (ALT): $45\text{ U/L}$ (decreased from $450\text{ U/L}$ on admission)

Due to the persistent systemic inflammatory response syndrome (SIRS) and severe pain, a contrast-enhanced computed tomography (CT) scan of the abdomen is obtained. The imaging demonstrates diffuse pancreatic enlargement with interstitial edema and $>30\%$ non-enhancement of the pancreatic parenchyma, consistent with acute necrotizing pancreatitis. Several acute peripancreatic fluid collections are noted. There is no evidence of retroperitoneal gas or pneumobilia.

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

An unresponsive 22-year-old male is brought to the emergency department by his parents. He has a history of type 1 diabetes mellitus but lost his insurance and ran out of his medication a week ago. Capillary blood glucose is $540\text{ mg/dL}$. Vital signs show a blood pressure of $85/50\text{ mm Hg}$, pulse of $128\text{/min}$, and respirations of $28\text{/min}$ with deep, sighing breaths. Laboratory results reveal an arterial pH of $7.15$, serum bicarbonate of $10\text{ mEq/L}$, and serum potassium of $4.8\text{ mEq/L}$. Urinalysis is strongly positive for ketones. Arrange the following management steps in the correct chronological sequence for the optimal treatment of this patient's acute condition.

A $68$-year-old man is evaluated in the intensive care unit for a new-onset fever and increased respiratory secretions. He has been receiving mechanical ventilation for $7$ days following a severe cerebrovascular accident. His temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, and pulse is $105/\text{min}$. Physical examination reveals coarse crackles in the right lower lung field. A chest radiograph demonstrates a new right lower lobe infiltrate. Endotracheal aspiration is performed, and empiric intravenous therapy with cefepime, tobramycin, and vancomycin is initiated.

Forty-eight hours later, the patient's temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$) and his oxygenation has steadily improved. The endotracheal aspirate culture grows $10^6\text{ CFU/mL}$ of *Pseudomonas aeruginosa*. Antimicrobial susceptibility testing indicates the organism is susceptible to cefepime, meropenem, and tobramycin, but resistant to levofloxacin. No other organisms are isolated. Which of the following is the most appropriate next step in the management of this patient's pharmacotherapy?

A 72-year-old man is evaluated in the intensive care unit for progressive lethargy and labored breathing. He was admitted 3 days ago for presumed urosepsis and is receiving broad-spectrum intravenous antibiotics. His temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is 82/50 mm Hg, pulse is 122/min, and respirations are 28/min. Physical examination shows a somnolent patient using accessory muscles of respiration.

Laboratory studies show the following:

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

A 42-year-old woman is newly diagnosed with limited cutaneous systemic sclerosis. She is highly anxious about the potential progression of her Raynaud phenomenon, which currently manifests as mild, infrequent vasospastic episodes triggered by cold exposure. During her clinic visit, she asks about the long-term management strategy for this condition if her symptoms worsen over time. You outline a stepwise therapeutic escalation pathway. Arrange the following management steps in the correct chronological order of therapeutic escalation, from the initial foundational intervention to the final rescue treatment for medically refractory, critical digital ischemia.

Review the following clinical presentations of patients with severe malabsorption or those receiving long-term parenteral nutrition. Match each clinical vignette to the specific underlying trace mineral deficiency it describes.

A 45-year-old woman presents to the clinic reporting pain and swelling in her wrists and the knuckles of both hands for the past 3 months. She mentions that her joints feel extremely stiff when she wakes up, typically taking about two hours to loosen up. Physical examination reveals tender, boggy swelling of the bilateral metacarpophalangeal and proximal interphalangeal joints. Initial laboratory testing is notable for an elevated erythrocyte sedimentation rate and a positive rheumatoid factor. Which of the following is the most appropriate initial disease-modifying pharmacotherapy for this patient?

A 68-year-old male is currently receiving care in the intensive care unit for acute respiratory distress syndrome secondary to severe acute pancreatitis. He has been mechanically ventilated for the past 11 days. Over the last 48 hours, his oxygen requirements have increased, and he has developed copious purulent endotracheal secretions. His temperature is 38.8°C (101.8°F), blood pressure is 110/65 mm Hg, and pulse is 112/min. Physical examination reveals coarse crackles in the right lung base. A portable chest radiograph demonstrates a new right lower lobe consolidation. Endotracheal aspirate and blood cultures are obtained, and the patient is empirically started on intravenous vancomycin, meropenem, and tobramycin.

Two days later, the patient's clinical status has improved, and he is afebrile. Blood cultures show no growth. The endotracheal aspirate culture yields heavy growth of *Enterobacter cloacae*. The antimicrobial susceptibility report is as follows:

Which of the following is the most appropriate next step in the pharmacologic management of this patient's infection?