All practice questions

A 78-year-old woman with a history of atrial fibrillation and a recent lapse in her anticoagulant medication presents to the emergency department with a 2-hour history of severe, acute-onset generalized abdominal pain. She reports nausea and one episode of vomiting. Her temperature is 37.2°C (99.0°F), pulse is 118/min and irregular, blood pressure is 138/86 mm Hg, and respirations are 20/min. Physical examination reveals a soft abdomen with minimal tenderness to palpation, which is strikingly disproportionate to the severity of her reported pain. Laboratory studies show a leukocyte count of 18,000/mm³ and a significantly elevated serum lactate level. Arrange the following management steps in the most appropriate sequential order for this patient.

During morning rounds on the inpatient hematology-oncology unit, a 42-year-old woman is evaluated for a new-onset fever. She was admitted seven days ago for induction chemotherapy to treat acute myeloid leukemia. Her temperature is 38.9°C (102.0°F), blood pressure is 118/74 mm Hg, pulse is 92/min, and respiratory rate is 16/min. The patient reports feeling fatigued but denies cough, dysuria, abdominal pain, or skin changes. Physical examination reveals a clean peripherally inserted central catheter site with no surrounding erythema, warmth, or induration. The lungs are clear to auscultation. Laboratory studies show a hemoglobin of 8.2 g/dL, platelet count of 45,000/mm³, and an absolute neutrophil count of 300/mm³. Renal and hepatic function panels are within normal limits. Blood and urine cultures have been obtained. Which of the following is the most appropriate initial pharmacotherapy for this patient?

A 34-year-old man is brought to the emergency department by emergency medical services after his partner witnessed him having an episode of rhythmic limb jerking and loss of consciousness lasting approximately 5 minutes. On arrival, he is deeply lethargic and only moans to painful stimuli. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $118/76$ mmHg, pulse is $112$/min, and respirations are $12$/min. Physical examination reveals a laceration on the lateral aspect of his tongue and generalized muscle tenderness.

Laboratory studies show:
Sodium: $140$ mEq/L
Potassium: $4.6$ mEq/L
Chloride: $104$ mEq/L
Bicarbonate: $12$ mEq/L
Blood urea nitrogen: $16$ mg/dL
Creatinine: $1.1$ mg/dL
Glucose: $118$ mg/dL

Arterial blood gas (room air):
pH: $7.17$
pCO $_2$: $34$ mmHg
pO $_2$: $78$ mmHg

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

Emergency medical responders rush a $62$-year-old male to the trauma bay for abrupt-onset dyspnea, left-sided pleuritic chest pain, and near-syncope that began two hours ago. The patient arrived yesterday from a transpacific business trip. His past medical history includes essential hypertension and hypercholesterolemia. Initial assessment reveals a blood pressure of $82/50$ mm Hg, a heart rate of $134$/min, and a respiratory rate of $32$/min. Pulse oximetry displays an oxygen saturation of $86\%$ despite administration of high-flow supplemental oxygen. Physical examination is notable for prominent jugular venous distention and a palpable parasternal heave. Auscultation of the lungs is unremarkable. An expedited point-of-care echocardiogram is performed, showing marked right ventricular enlargement, interventricular septal bowing into the left ventricle, and severe hypokinesis of the right ventricular free wall with relative apical sparing.

Which of the following are the most appropriate next steps in the management of this patient? (Select all that apply)

A rapid response code is called for a $71$-year-old man on his fourth day in the hospital after an emergency bowel resection with primary anastomosis for acute mesenteric ischemia. The patient is suddenly experiencing severe, agonizing abdominal pain and difficulty breathing. Vital signs are temperature $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure $84/52\text{ mmHg}$, pulse $138/\text{min}$, and respirations $28/\text{min}$. Oxygen saturation is $94\%$ on $4\text{ L/min}$ via nasal cannula. On physical examination, the patient appears ashen and diaphoretic. Lung auscultation reveals shallow breathing with bibasilar crackles. The abdomen is board-like with diffuse rigidity, severe tenderness to light palpation, and absent bowel sounds. Laboratory studies reveal a leukocyte count of $24,000/\text{mm}^3$ and a serum lactate level of $5.8\text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old man with a history of alcohol-related cirrhosis is brought to the emergency department by his family due to worsening confusion and increased abdominal swelling over the past 3 days. His temperature is 38.2°C (100.8°F), pulse is 98/min, and blood pressure is 100/60 mm Hg. Physical examination reveals scleral icterus and a distended abdomen with a positive fluid wave. There is diffuse, mild abdominal tenderness without rebound or guarding. Neurologic examination shows bilateral asterixis. Laboratory studies show a serum albumin of 2.5 g/dL and creatinine of 1.4 mg/dL. A diagnostic paracentesis is performed, yielding cloudy fluid with the following analysis:

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

Emergency medical services bring a $61$-year-old woman to the resuscitation bay immediately after she collapsed at home. She regained consciousness after a few minutes but currently complains of severe, abrupt-onset dyspnea and right-sided chest pain. Her surgical history is notable for an uncomplicated right total hip arthroplasty performed three weeks ago.

Vital signs are temperature $37.9^{\circ}$ C ($100.2^{\circ}$ F), blood pressure $72/46$ mmHg, heart rate $134$/min, and respiratory rate $28$/min. Oxygen saturation is $85\%$ on ambient air. Physical examination shows elevated jugular venous pressure and a loud pulmonary component of the second heart sound ($P_2$). The lungs are clear to auscultation bilaterally. The right calf exhibits mild asymmetric edema.

A rapid bedside echocardiogram reveals severe right ventricular dilation with marked hypokinesis of the free wall and normal apical contractility.

Arterial blood gas analysis on ambient air shows:

pH: $7.22$
$PaCO_2$: $28$ mmHg
$PaO_2$: $54$ mmHg
$HCO_3^-$: $11$ mEq/L

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

Match each infectious disease clinical scenario with the most appropriate targeted antimicrobial therapy or post-exposure prophylaxis regimen.

A 19-year-old man is rushed to the trauma center by emergency medical services after being struck by a fast-moving motor vehicle while crossing the street. On arrival, his blood pressure is 72/44 mmHg, heart rate is 140/min, and respiratory rate is 26/min. Pulse oximetry shows 96% on a non-rebreather mask. The airway is patent, and breath sounds are present and equal bilaterally. Trachea is midline. Peripheral pulses are rapid and thready. He immediately receives 1 L of intravenous Ringer's lactate and 1 unit of uncrossmatched packed red blood cells. Reassessment vital signs show a blood pressure of 78/48 mmHg and a heart rate of 130/min. Physical examination reveals a distended abdomen with diffuse guarding and rebound tenderness. The pelvis is mechanically stable to gentle compression. A focused assessment with sonography for trauma (FAST) exam demonstrates a prominent anechoic stripe in the right upper quadrant between the liver and kidney. Which of the following is the most appropriate next step in management?

Correlate the following clinical conditions with their most characteristic acid-base and electrolyte laboratory profile.

During a routine postnatal follow-up visit, a $31$-year-old female reports severe, persistent fatigue, feeling continuously cold, and experiencing dizziness upon standing. She delivered a healthy infant $5$ months ago via emergency cesarean delivery that was complicated by a severe hemorrhage requiring the transfusion of $4$ units of packed red blood cells. Since the delivery, she has been unable to produce breast milk and her menstrual cycles have not returned. Her blood pressure is $92/58$ mm Hg while seated and $80/50$ mm Hg upon standing. Pulse is $62$/min. Laboratory evaluation reveals the following:

Hemoglobin: $11.2$ g/dL
Sodium: $132$ mEq/L
Thyroid-stimulating hormone (TSH): $0.8$ $\mu$ U/mL (Normal: $0.4-4.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.3$ ng/dL (Normal: $0.7-1.9$ ng/dL)

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

A 65-year-old man presents to the clinic with a 3-month history of progressive difficulty swallowing. Initially, he had trouble only with solid foods like meat and bread, but now he struggles to swallow liquids. He also reports a 9-kg (20-lb) unintentional weight loss over the same period. He has a 40-pack-year smoking history and consumes 2 to 3 alcoholic beverages daily. Physical examination is unremarkable. Routine laboratory tests show a new-onset microcytic anemia. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient.

A 68-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) (FEV1 $35\%$ of predicted) and ischemic cardiomyopathy (left ventricular ejection fraction $30\%$) is brought to the emergency department due to severe shortness of breath that acutely worsened over the past 6 hours. He reports waking up from sleep gasping for air and has a cough productive of pink, frothy sputum. On arrival, his temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $178/102\text{ mmHg}$, pulse is $118\text{/min}$, and respiratory rate is $32\text{/min}$. Oxygen saturation is $84\%$ on room air. Physical examination reveals the use of accessory muscles of respiration, jugular venous distention to $12\text{ cm H}_2\text{O}$, and a third heart sound (S3). Lung auscultation reveals diffuse expiratory wheezing and bibasilar crackles. Arterial blood gas analysis on room air shows:

pH: $7.19$
PaCO2: $60\text{ mmHg}$
PaO2: $50\text{ mmHg}$
HCO3-: $22\text{ mEq/L}$

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

A 23-year-old woman with a history of asthma presents to the emergency department due to severe shortness of breath that began 6 hours ago. She has used her albuterol inhaler multiple times at home without relief. On physical examination, she appears highly anxious and is using accessory muscles to breathe. Her temperature is 37.0 °C (98.6 °F), blood pressure is 135/85 mmHg, pulse is 128/min, and respiratory rate is 32/min. Pulse oximetry shows an oxygen saturation of 90% on room air. Auscultation reveals markedly decreased breath sounds bilaterally with faint, diffuse expiratory wheezing.

An arterial blood gas analysis on room air demonstrates:
pH: 7.34
$PaCO_2$: 46 mm Hg
$PaO_2$: 58 mm Hg
$HCO_3^-$: 24 mEq/L

Which of the following is the most accurate interpretation of this patient's clinical presentation and laboratory findings?

A 68-year-old man is evaluated in the cardiac intensive care unit on day 4 of an admission for an anterior ST-segment elevation myocardial infarction. He initially presented 14 hours after symptom onset and underwent primary percutaneous coronary intervention of the left anterior descending artery. Over the past hour, he has developed severe dyspnea, agitation, and diaphoresis. His medical history includes hypertension, type 2 diabetes mellitus, and a 45-pack-year smoking history with known chronic obstructive pulmonary disease.

Vital signs:
Temperature: 37.2°C (99.0°F)
Blood pressure: 82/54 mm Hg
Pulse: 124/min
Respirations: 28/min
Oxygen saturation: 87% on room air

Physical examination reveals cool, clammy extremities with 1+ bilateral pitting edema. Jugular venous pressure is estimated at 12 cm $H_2O$. Lung auscultation reveals bilateral basilar crackles and diffuse expiratory wheezing. Cardiac auscultation reveals a regular tachycardia and a new, harsh, grade 4/6 holosystolic murmur with a palpable thrill at the left lower sternal border.

Arterial blood gas analysis on room air:
pH: 7.27
$PaO_2$: 55 mm Hg
$PaCO_2$: 32 mm Hg
$HCO_3^-$: 14 mEq/L

A pulmonary artery catheter is placed, yielding the following oxygen saturation ($S_vO_2$) data:

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

A 59-year-old male is brought to the emergency department by his spouse due to the sudden onset of crushing substernal chest pain that began 1 hour ago. He also reports profound weakness and diaphoresis. His medical history is significant for type 2 diabetes mellitus and hypertension. His current temperature is 37.1°C (98.8°F), blood pressure is 80/50 mmHg, heart rate is 110/min, and respiratory rate is 20/min. Pulse oximetry shows 95% on room air. On physical examination, the patient appears pale and diaphoretic. Jugular venous pulsation is visible 8 cm above the sternal angle. The lungs are clear to auscultation bilaterally with no wheezes or crackles. Cardiac auscultation reveals a regular tachycardia with no murmurs, rubs, or gallops. The extremities are cool and clammy with delayed capillary refill. Laboratory studies show a serum bicarbonate of 18 mEq/L and a lactate level of 4.5 mmol/L. An ECG reveals 3-mm ST-segment elevations in leads II, III, and aVF, as well as reciprocal ST-segment depressions in leads I and aVL. Which of the following is the most appropriate next step in the management of this patient's hemodynamic instability?

During a routine follow-up appointment, a $69$-year-old man is evaluated in the outpatient clinic for a $1$-month history of steadily increasing abdominal girth and swelling in both legs. He has a known history of severe chronic obstructive pulmonary disease (COPD) and is adherent to an inhaled corticosteroid, a long-acting beta-agonist, and a long-acting muscarinic antagonist. He quit smoking $3$ years ago after a $45$-pack-year history. The patient reports worsening exertional fatigue but explicitly denies waking up gasping for air at night or having trouble breathing when lying flat. Vital signs reveal a blood pressure of $126/80$ mm Hg, a heart rate of $92$/min, and a respiratory rate of $18$/min. Pulse oximetry shows an oxygen saturation of $87\%$ on room air. Physical examination demonstrates distended neck veins. Lung auscultation reveals globally decreased breath sounds and a prolonged expiratory phase, with no crackles appreciated. Cardiac examination shows a prominent parasternal impulse and a holosystolic murmur at the left lower sternal border that augments in intensity during inspiration. Abdominal exam is notable for a tender, palpable liver edge $4$ cm below the right costal margin. Bilateral $3+$ pitting edema is present up to the knees. Which of the following interventions is most likely to slow the progression of this patient's underlying cardiac condition and improve long-term survival?

An $84$-year-old woman is brought to the emergency department from her assisted living facility due to a $3$-day history of progressively worsening nausea, bilious vomiting, and colicky abdominal pain. She has not had a bowel movement or passed flatus for $36$ hours. Her medical history is significant for severe osteoporosis and dementia. Over the past year, she has unintentionally lost $10\text{ kg}$ ($22\text{ lb}$). Vital signs show a temperature of $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure of $96/60\text{ mmHg}$, and pulse of $115/\text{min}$. On physical examination, the abdomen is distended, tympanic, and exhibits high-pitched, tinkling bowel sounds. There is diffuse abdominal tenderness but no overt rigidity. Passive extension and internal rotation of the right hip elicits sharp pain radiating down the medial aspect of the right thigh. Laboratory studies reveal a leukocyte count of $15,200/\text{mm}^3$ and a serum lactate of $3.4\text{ mmol/L}$. Computed tomography of the abdomen and pelvis with intravenous contrast demonstrates markedly dilated loops of small bowel with a transition point in the right pelvis. At the transition point, a small segment of bowel passes through the obturator foramen; this segment shows absent mucosal enhancement. Which of the following is the most appropriate next step in management?

A rapid response team is called to evaluate a 45-year-old woman on the general medical ward due to acute-onset lethargy. The patient was admitted 24 hours ago for a severe exacerbation of ulcerative colitis, presenting with numerous large-volume, watery bowel movements per day. Over the past 12 hours, she has received three doses of intravenous hydromorphone to manage severe abdominal cramping. On physical examination, her temperature is 37.1°C (98.8°F), blood pressure is 105/65 mmHg, pulse is 112/min, and respiratory rate is 8/min with shallow breathing. She is difficult to arouse but withdraws appropriately to painful stimuli.

Stat laboratory studies reveal the following:
Serum sodium: 135 mEq/L
Serum potassium: 3.1 mEq/L
Serum chloride: 115 mEq/L
Serum bicarbonate: 10 mEq/L
Blood urea nitrogen: 42 mg/dL
Serum creatinine: 1.8 mg/dL

Arterial blood gas analysis on room air shows:
pH: 7.10
PaO2: 68 mmHg
PaCO2: 36 mmHg

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

A $54$-year-old man with a history of hepatitis C virus infection and compensated cirrhosis is brought to the emergency department after vomiting bright red blood twice in the past hour. On presentation, his blood pressure is $88/56$ mm Hg, and his heart rate is $115$/min. He is lethargic but protecting his airway. Physical examination reveals scleral icterus, spider angiomata, and a distended abdomen with a positive fluid wave. Arrange the following interventions in the most appropriate chronological order for managing this patient's acute presentation.