All practice questions

Following a fall onto an outstretched hand during a snowboarding competition, a collegiate athlete presents with worsening right wrist discomfort. The patient specifically notes a deep ache near the base of the thumb that is exacerbated by gripping objects. On physical examination, there is mild edema and focal tenderness when palpating the depression between the extensor pollicis longus and the extensor pollicis brevis tendons. Range of motion at the radiocarpal joint is slightly limited by pain. Standard four-view radiographs of the wrist reveal no cortical step-offs, radiolucent lines, or malalignment. Which of the following is the most appropriate next step in management?

A 34-year-old man is evaluated in the intensive care unit 3 days after sustaining a severe closed head injury in a high-speed motor vehicle collision. On physical examination, he is comatose, has no spontaneous respirations, and exhibits absent pupillary, corneal, and gag reflexes. An apnea test is positive, and the patient is declared brain dead. The patient is unmarried, has no children, and has no written living will or designated healthcare proxy. A review of his state records reveals that he is actively registered on the state organ donor registry. His parents are informed of his passing and are approached by the organ procurement organization. The parents become irate, citing strict religious beliefs that require the body to remain completely intact for burial. They explicitly refuse to allow any organ donation and threaten to file a lawsuit against the hospital if their son is taken to the operating room. A close friend of the patient is present and insists the patient registered as a donor intentionally. Which of the following is the most appropriate course of action regarding the organ donation?

A 72-year-old woman is brought to the emergency department after a syncopal episode. She is currently conscious but complains of severe dizziness and chest pressure. Her blood pressure is 80/50 mm Hg, and her heart rate is 35/min. Arrange the following management steps in the most appropriate chronological sequence according to standard Advanced Cardiovascular Life Support (ACLS) guidelines for symptomatic bradycardia.

An academic medical center conducts a single-center randomized controlled trial comparing a novel wound closure method to standard suturing in patients undergoing exploratory laparotomy. The primary outcome is the incidence of surgical site infection within $30$ days. The trial enrolls $120$ patients, with $60$ randomly assigned to each group. The results demonstrate a $30$-day infection rate of $8.3\%$ in the novel closure group and $15.0\%$ in the standard suturing group. The corresponding relative risk (RR) is $0.55$, with a $95\%$ confidence interval (CI) of $0.20$ to $1.51$ and a p-value of $0.28$. Based on these findings, the hospital committee decides against adopting the novel method, citing that it is definitively not effective. Which of the following is the most accurate statistical evaluation of this trial's results and the committee's conclusion?

A 4-year-old girl is brought to the clinic for a routine well-child evaluation. She was diagnosed with acute lymphoblastic leukemia eight months ago and is currently undergoing maintenance chemotherapy. Her mother provides her immunization record, which shows she received all age-appropriate vaccines up to her 18-month visit. During the current visit, the mother expresses concern that her daughter is unable to skip or tie her shoelaces. Observation in the clinic reveals the child can hop on one foot, correctly name four colors, and draw a person with three distinct body parts. Physical examination reveals a well-nourished child with normal cardiovascular and respiratory findings. Based on the patient's current status and developmental presentation, which of the following is the most appropriate next step in her preventive care?

During a routine second-trimester prenatal visit, a 24-year-old primigravida is informed that her rapid plasma reagin and fluorescent treponemal antibody absorption tests are positive. The physician diagnoses her with early latent syphilis and strongly recommends immediate treatment with intramuscular penicillin G to prevent congenital syphilis. The physician explains the high risk of stillbirth and severe fetal anomalies if the infection is left untreated. The patient exhibits significant distress upon seeing the syringe and declines the medication. She states, "I have a severe phobia of needles. I cannot do this. I will drink whatever herbal teas are necessary, but I refuse to be injected." The physician assesses that the patient has intact decision-making capacity and understands the severe consequences for the fetus. Which of the following is the most appropriate next step in management?

A large tertiary care center is preparing to integrate a novel, automated continuous insulin infusion algorithm into the electronic health record (EHR) for the medical intensive care unit. Because intravenous insulin administration is highly prone to errors, the patient safety committee decides to proactively evaluate this system prior to its deployment. They initiate a Failure Mode and Effects Analysis (FMEA). Arrange the following procedural steps of the FMEA in the correct chronological sequence.

A 62-year-old man comes to the clinic because of severe, excruciating pain in his right great toe that began abruptly overnight. He cannot bear weight on his right foot or tolerate the bedsheets touching his toe. His past medical history is significant for hypertension, type 2 diabetes mellitus, and stage 4 chronic kidney disease. Current medications include amlodipine, insulin glargine, and lisinopril. His temperature is 37.6°C (99.7°F), blood pressure is 135/85 mmHg, and pulse is 92/min. Physical examination reveals a markedly erythematous, swollen, warm, and exquisitely tender right first metatarsophalangeal joint. Range of motion is severely limited due to pain. Laboratory studies show a serum creatinine level of 2.6 mg/dL (baseline 2.5 mg/dL) and a serum uric acid level of 5.8 mg/dL (normal: 4.0-8.5 mg/dL). Joint aspiration yields fluid with a leukocyte count of 35,000/mm³ and negatively birefringent, needle-shaped crystals. Gram stain shows no organisms. Which of the following is the most appropriate next step in management?

A 56-year-old man is brought to the emergency department by his wife due to a 2-day history of diffuse abdominal discomfort, subjective fever, and increasing confusion. His medical history is significant for decompensated alcohol-associated cirrhosis. He takes furosemide, spironolactone, and lactulose at home. His temperature is 38.2°C (100.8°F), blood pressure is 102/64 mmHg, pulse is 98/min, and respirations are 16/min. Physical examination demonstrates scleral icterus and multiple spider angiomas on the anterior chest. The abdomen is distended with a positive fluid wave and shifting dullness. There is diffuse, mild abdominal tenderness to palpation, but no rebound tenderness or rigidity is present. Neurologic examination reveals a coarse, flapping tremor when the patient's wrists are extended, and he is oriented to person only. Which of the following is the most appropriate next step in management?

A $52$-year-old man with a history of recurrent pulmonary infections and bronchiectasis is brought to the emergency department after coughing up approximately $700$ mL of bright red blood over the past two hours. On arrival, he is in severe respiratory distress, lethargic, and coughing continuously. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $88/54\text{ mm Hg}$, pulse of $128\text{/min}$, and respiratory rate of $28\text{/min}$. Oxygen saturation is $85\%$ on high-flow oxygen. Auscultation reveals coarse crackles and diminished breath sounds over the right hemithorax. Large-bore intravenous access is established. Arrange the following interventions in the most appropriate sequential order for the acute management of this patient's condition.

A 72-year-old female presents to the gynecology clinic reporting a six-month history of severe vulvar pruritus and a painful, non-healing sore. Her past medical history is significant for hypertension and lichen sclerosus. Physical examination reveals a 3.5-cm ulcerated, indurated plaque located on the right labium majus. Palpation of the right inguinal region identifies a firm, mobile, 1.5-cm lymph node. The left groin is unremarkable. Arrange the following steps in the most appropriate chronological sequence for the diagnosis and management of this patient's condition.

A $67$-year-old woman is brought to the emergency department from a skilled nursing facility due to increasing lethargy, shortness of breath, and severe, watery diarrhea for the past $48$ hours. She has a history of severe chronic obstructive pulmonary disease (COPD), heart failure with preserved ejection fraction, and recurrent urinary tract infections. Her daily medications include tiotropium, formoterol, lisinopril, and as-needed albuterol.

On presentation, she is somnolent but arousable. Temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $98/60\text{ mm Hg}$, pulse is $115/\text{min}$, and respirations are $24/\text{min}$. Pulse oximetry shows $89\%$ on $2\text{ L/min}$ oxygen via nasal cannula.

Physical examination reveals dry mucous membranes, decreased skin turgor, and mild abdominal distension with hyperactive bowel sounds. Lung examination shows diminished breath sounds bilaterally with a prolonged expiratory phase. Cardiac examination reveals a regular tachycardia without murmurs or gallops.

A chest radiograph shows hyperinflated lungs but no focal infiltrates or signs of pulmonary edema.

In addition to aggressive intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient's respiratory status?

An emergency medical services team brings a 67-year-old man to the hospital due to three days of progressive breathlessness. He reports a concurrent increase in cough frequency and a change in sputum from clear to thick, yellowish-green. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, severe chronic obstructive pulmonary disease, and a 45-pack-year smoking history. Current vital signs reveal a temperature of $37.8^\circ\text{C}$ ($100^\circ\text{F}$), heart rate of $108/\text{min}$, blood pressure of $138/86\text{ mm Hg}$, and respiratory rate of $24/\text{min}$. Oxygen saturation is $88\%$ on room air. Physical examination demonstrates a barrel-shaped chest with the use of accessory muscles of respiration. Auscultation reveals a prolonged expiratory phase with diffuse wheezing bilaterally. There are no crackles, and the jugular veins are not distended. Trace bilateral pedal edema is present, which the patient states is unchanged from his baseline. Arterial blood gas analysis on room air shows:

pH: $7.31$
PaCO $_2$: $62\text{ mm Hg}$
PaO $_2$: $58\text{ mm Hg}$
HCO $_3^-$: $30\text{ mEq/L}$

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

A 52-year-old man with newly diagnosed acute myeloid leukemia is evaluated on hospital day 10 of induction chemotherapy due to a new-onset fever. Over the past 4 hours, his temperature has risen to a maximum of 38.7°C (101.7°F). He reports mild generalized fatigue but denies cough, shortness of breath, dysuria, abdominal pain, or diarrhea. Vital signs show a blood pressure of 118/74 mmHg, pulse of 92/min, and respiratory rate of 16/min. He has an indwelling right internal jugular central venous catheter; examination of the insertion site reveals it to be clean and dry without any surrounding erythema, induration, or tenderness. Cardiopulmonary and abdominal examinations are unremarkable. There are no skin rashes or mucosal ulcerations. Laboratory studies reveal:

Peripheral blood and catheter-drawn blood cultures have been obtained. Which of the following is the most appropriate empiric antimicrobial regimen for this patient?

A 32-year-old woman presents to the clinic with a 6-month history of progressive exertional dyspnea, fatigue, and occasional exertional syncope. Physical examination reveals a right ventricular heave, a loud pulmonic component of the second heart sound (P2), and clear lung fields. A transthoracic echocardiogram demonstrates right atrial and ventricular enlargement with an estimated right ventricular systolic pressure of $65 \text{ mm Hg}$. Left ventricular size and function are normal, with no left-sided valvular abnormalities. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the standard evaluation and definitive management of this patient's condition.

A 54-year-old man with a known history of alcohol-associated cirrhosis presents to the emergency department after vomiting a large amount of bright red blood. On presentation, his blood pressure is 85/55 mm Hg, and his pulse is 120/min. He is lethargic but is maintaining his airway and oxygenating well on room air. Arrange the following management steps in the most appropriate chronological sequence.

A 69-year-old man is evaluated in the observation unit due to two days of worsening breathlessness, orthopnea, and a persistent cough producing pink-tinged sputum. His medical history includes long-standing essential hypertension, a myocardial infarction five years ago, and a 45 pack-year smoking history. Current medications include aspirin, lisinopril, and atorvastatin.

Vital signs are temperature 37.1°C (98.8°F), blood pressure 162/94 mm Hg, pulse 108/min, and respirations 24/min. Pulse oximetry displays 88% on room air.

Physical examination reveals a patient in moderate respiratory distress using accessory muscles of respiration. Auscultation of the lungs demonstrates a prolonged expiratory phase with high-pitched wheezes in all lung fields, accompanied by fine bibasilar crackles. Cardiac auscultation identifies a laterally displaced point of maximal impulse and a low-frequency diastolic sound immediately following S2. There is 2+ pitting edema extending to the mid-calves bilaterally.

An arterial blood gas analysis on room air shows:
pH: 7.50
PaCO2: 28 mm Hg
PaO2: 58 mm Hg
HCO3-: 21 mEq/L

Which of the following interventions is the most appropriate initial treatment for this patient's underlying condition?

Paramedics transport a 30-year-old woman, gravida 2, para 1, at 34 weeks gestation to the emergency department for severe, acute-onset difficulty breathing. She has a history of moderate persistent asthma but stopped her inhaled medications weeks ago due to concerns about fetal safety. Over the past 90 minutes in the emergency department, she has been treated with continuous nebulized albuterol and ipratropium, as well as intravenous methylprednisolone. Despite these measures, her work of breathing remains highly labored. Vital signs are temperature $37.0^\circ C$ ($98.6^\circ F$), blood pressure $128/78$ mm Hg, pulse $126$/min, and respirations $32$/min. Pulse oximetry is $91\%$ on a non-rebreather mask. Physical examination reveals a lethargic patient sitting in a tripod position, using accessory muscles of respiration. Auscultation shows notably decreased breath sounds bilaterally with only faint expiratory wheezes. There is no jugular venous distention or lower extremity edema. An arterial blood gas analysis on the current oxygen setting shows:

pH: $7.33$
$PaCO_2$: $46$ mm Hg
$PaO_2$: $64$ mm Hg
$HCO_3^-$: $24$ mEq/L

Continuous fetal heart rate monitoring demonstrates a baseline of 150/min with minimal variability and recurrent late decelerations. Which of the following is the most appropriate next step in management?

A $71$-year-old man is evaluated in the intensive care unit for worsening shortness of breath and increasing somnolence. He was admitted $2$ days ago for an acute exacerbation of chronic obstructive pulmonary disease (COPD) and suspected pneumonia. His admission medications include intravenous piperacillin-tazobactam, vancomycin, methylprednisolone, and scheduled albuterol-ipratropium nebulizers. Medical history is significant for severe COPD (FEV $_1$ $45\%$ of predicted), ischemic cardiomyopathy (left ventricular ejection fraction $30\%$), and stage $3$ chronic kidney disease.

Temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse is $112\text{/min}$, blood pressure is $160/90\text{ mm Hg}$, and respirations are $28\text{/min}$. Oxygen saturation is $86\%$ on a $4\text{ L/min}$ nasal cannula. Physical examination reveals a lethargic but arousable patient in respiratory distress. Jugular venous pressure is estimated at $11\text{ cm H}_2\text{O}$. Lung auscultation reveals bilateral basilar crackles and diffuse expiratory wheezes. Cardiac examination shows a regular, rapid rhythm with a prominent S $_3$ gallop. There is $2+$ bilateral pitting edema extending to the knees.

Laboratory results are as follows:

An arterial blood gas on the current oxygen setting shows:
pH: $7.26$
PaO $_2$: $56\text{ mm Hg}$
PaCO $_2$: $36\text{ mm Hg}$
$\text{HCO}_3^-$: $15\text{ mEq/L}$

A sputum culture obtained on admission has returned positive for Streptococcus pneumoniae that is susceptible to ceftriaxone, azithromycin, and levofloxacin.

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

A 52-year-old male presents to the outpatient clinic reporting a 6-month history of worsening fatigue, decreased libido, and erectile dysfunction. He also notes chronic constipation and feeling unusually sluggish. His medical history is unremarkable, and he takes no medications. Vital signs show a blood pressure of $110/70 \text{ mmHg}$ and a heart rate of $56/\text{min}$. Physical examination reveals pale, dry skin and a delay in the relaxation phase of the deep tendon reflexes. Visual fields are full to confrontation.

Laboratory results are as follows:

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