All practice questions

A series of critically ill patients presenting with hypotension and tachycardia undergo pulmonary artery catheterization for hemodynamic monitoring in the intensive care unit. Match each specific hemodynamic profile obtained (Profiles 1 through 4) with the most likely underlying cardiovascular or cardiopulmonary pathology.

(Reference ranges: Right atrial [RA] pressure 2-8 mmHg; Pulmonary artery [PA] pressure 15-30/4-12 mmHg; Pulmonary capillary wedge pressure [PCWP] 6-12 mmHg; Cardiac index [CI] 2.5-4.0 L/min/m²).

Emergency medical services bring a 58-year-old male to the acute care bay complaining of relentless, diffuse abdominal pain that started two days ago. The patient reports having vomited bilious material several times and notes a complete inability to pass stool or flatus since the pain began. His surgical history is significant for an open appendectomy a decade ago. Vital signs show a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), a heart rate of $122/\text{min}$, and a blood pressure of $86/54\text{ mmHg}$. Abdominal examination demonstrates marked distension, tympany to percussion, and exquisite diffuse tenderness accompanied by board-like rigidity and rebound tenderness. Laboratory evaluation is notable for a leukocyte count of $19,500/\text{mm}^3$ and a serum lactate level of $4.8\text{ mmol/L}$. Venous blood gas reveals a pH of $7.28$ and a bicarbonate concentration of $14\text{ mEq/L}$. Which of the following is the most appropriate next step in management?

A 28-year-old woman is brought to the emergency department due to a 2-day history of worsening, diffuse abdominal pain and recurrent vomiting of greenish material. She reports that her pain was initially crampy and intermittent but has become constant and severe over the past 6 hours. She has not had a bowel movement or passed flatus since the symptoms began. Her medical history is significant for stricturing ileal Crohn's disease, for which she was previously treated with infliximab, but she discontinued all medications a year ago. Her temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), pulse is $124/\text{min}$, blood pressure is $88/54 \text{ mmHg}$, and respirations are $22/\text{min}$. Physical examination reveals a distended, tympanitic abdomen with absent bowel sounds. There is diffuse tenderness with marked guarding and rebound tenderness in the right lower quadrant. Laboratory studies show a leukocyte count of $21,000/\text{mm}^3$ with $15\%$ bands, and a serum lactate level of $4.8 \text{ mmol/L}$. An abdominal CT scan with intravenous contrast demonstrates markedly dilated loops of small intestine with a distinct transition point in the terminal ileum. There is circumferential thickening of the terminal ileum, pneumatosis intestinalis, and moderate free fluid in the pelvis. Which of the following is the most appropriate next step in management?

A $76$-year-old man from a nursing home is brought to the emergency department due to a $3$-day history of progressive abdominal distension, colicky abdominal pain, and obstipation. His temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $118/76$ mm Hg, and pulse is $92$/min. Physical examination reveals a markedly distended, tympanitic abdomen without rebound tenderness or guarding. Arrange the following management steps in the most appropriate sequential order for this patient.

Paramedics arrive at the emergency department with a lethargic 65-year-old man in severe respiratory distress. His wife reports that his breathing has grown progressively labored over the last two days, accompanied by a persistent cough. His medical background is significant for ischemic cardiomyopathy (ejection fraction $35\%$), severe chronic obstructive pulmonary disease (COPD), and hypothyroidism. Home medications include lisinopril, metoprolol, tiotropium, and levothyroxine.

Vital signs upon arrival show a temperature of $37.2^\circ \text{C}$ ($99.0^\circ \text{F}$), blood pressure of $145/88 \text{ mm Hg}$, heart rate of $118\text{/min}$, and respiratory rate of $28\text{/min}$. Oxygen saturation is $84\%$ on ambient air.

On physical examination, the patient is somnolent but awakens when his name is called loudly. His jugular venous pressure is normal at $7 \text{ cm H}_2\text{O}$. Auscultation of the lungs reveals diminished air entry globally, a notably prolonged expiratory phase, and diffuse expiratory wheezing. No crackles or rales are heard. Cardiac auscultation demonstrates tachycardia with a regular rhythm and no $S_3$ gallop. The lower extremities are free of edema.

Initial laboratory results are as follows:

Chest radiograph reveals hyperinflated lungs with flattened hemidiaphragms; there are no focal consolidations, pleural effusions, or pulmonary vascular congestion.

Noninvasive positive pressure ventilation (NIPPV) is initiated, and the patient's respiratory effort improves slightly.

Which of the following represents the most accurate diagnostic assessment and most appropriate next step in pharmacologic management?

A $62$-year-old retired mechanic comes to the outpatient clinic with a $3$-day history of progressively worsening dyspnea. He states that his daily morning cough has become more frequent and is now producing thick, dark yellow sputum in significantly greater amounts than usual. His medical history is significant for chronic obstructive pulmonary disease and hypertension. He previously smoked $2$ packs of cigarettes daily for $20$ years before quitting $5$ years ago. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), pulse is $98/\text{min}$, respirations are $22/\text{min}$, and blood pressure is $135/85\text{ mmHg}$. Pulse oximetry shows $93\%$ on ambient air. Pulmonary auscultation demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. Cardiovascular examination is unremarkable with no jugular venous distention. There is no peripheral edema. Which of the following therapeutic interventions are indicated for this patient? (Select all that apply)

A 58-year-old woman presents to the clinic complaining of progressive fatigue, generalized weakness, and a tingling sensation in her lower extremities that has steadily worsened over the past four months. Her past medical history is significant for vitiligo and Hashimoto thyroiditis, for which she takes daily levothyroxine. Vital signs are temperature 36.8°C (98.2°F), blood pressure 118/76 mmHg, heart rate 82/min, and respiratory rate 14/min. Physical examination reveals pale conjunctivae, a smooth and beefy-red tongue, and decreased vibratory sensation in both feet.

Laboratory results are as follows:

A peripheral blood smear demonstrates macro-ovalocytes and several neutrophils with six or more lobes.

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

A 76-year-old woman is evaluated in the clinic prior to an elective right total knee arthroplasty scheduled for the following week. She has a history of osteoarthritis and well-controlled essential hypertension. She reports no new symptoms and specifically denies dysuria, urinary frequency, urgency, suprapubic pain, fever, or chills. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $128/78\text{ mm Hg}$, and pulse is $76/\text{min}$. Physical examination of the abdomen and costovertebral angles is unremarkable. As part of her preoperative evaluation, a urinalysis is obtained which shows $15$ white blood cells/hpf and is positive for leukocyte esterase and nitrites. A subsequent urine culture grows $>10^5\text{ CFU/mL}$ of Escherichia coli that is susceptible to ceftriaxone, ciprofloxacin, trimethoprim-sulfamethoxazole, and nitrofurantoin. Which of the following is the most appropriate management regarding these laboratory findings?

The intensive care team is evaluating a 64-year-old male who was intubated overnight for progressive hypoxemic and hypercapnic respiratory failure. The patient was admitted to the hospital 48 hours ago for community-acquired pneumonia. His medical history is significant for severe chronic obstructive pulmonary disease (COPD) and hypertension. He is currently sedated and receiving mechanical ventilation.

Current medications include intravenous vancomycin, cefepime, azithromycin, and continuous infusions of propofol and fentanyl.

Current ventilator settings (Volume Assist-Control):

Arterial blood gas (on current settings):

Serum chemistry shows a lactate level of 4.2 mmol/L. Sputum cultures collected at the time of admission are now growing moderate *Streptococcus pneumoniae* that is susceptible to ceftriaxone, levofloxacin, and penicillin.

Physical examination reveals coarse breath sounds bilaterally with a prolonged expiratory phase. Cardiovascular examination reveals regular rate and rhythm with no murmurs. Jugular venous pressure is estimated at 6 cm H $_2$ O (normal < 8 cm H $_2$ O). There is no lower extremity edema.

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

A 69-year-old man presents to the emergency department complaining of progressively worsening shortness of breath over the past 2 days. His medical history is significant for chronic obstructive pulmonary disease, essential hypertension, and a myocardial infarction 5 years ago. The patient reports a cough productive of clear sputum and states he has been sleeping in his recliner chair because lying flat makes him feel as though he is suffocating. His temperature is 37.0 C (98.6 F), blood pressure is 168/96 mmHg, pulse is 108/min, and respiratory rate is 24/min. Oxygen saturation is 90% on room air. On physical examination, the patient is in moderate respiratory distress and is using accessory muscles of respiration. Lung auscultation demonstrates bilateral end-expiratory wheezes and prominent crackles in the lower two-thirds of both lung fields. Cardiac auscultation reveals a regular tachycardia with a distinct third heart sound (S3). The jugular venous pressure is 12 cm H2O. Which of the following findings is most likely to be present on this patient's chest radiograph?

An emergency response team brings a 45-year-old male industrial worker to the trauma center after a heavy steel beam collapsed, briefly pinning his lower torso against a concrete floor. On arrival, he is groggy but vigorously localizes to painful stimuli. His temperature is 36.5°C (97.7°F), blood pressure is 82/44 mmHg, heart rate is 134/min, and respiratory rate is 24/min. Pulse oximetry shows 98% on high-flow oxygen. Primary survey reveals a patent airway and bilateral breath sounds without adventitious noises. The trachea is midline, and neck veins are flat. Radial pulses are barely palpable, while femoral pulses are weak but present. A large ecchymosis is visible across the infraumbilical region, and the abdomen appears distended. Pelvic rock testing reveals no mechanical instability. Intravenous access is established with two large-bore peripheral catheters, and rapid crystalloid resuscitation is initiated. Which of the following is the most appropriate next step in the evaluation of this patient?

A previously healthy $59$-year-old male is brought to the surgical triage unit by his family after developing sudden, severe, and constant lower abdominal pain accompanied by multiple episodes of bilious emesis. The symptoms began $12$ hours prior to arrival, and he has not passed stool or flatus since the onset. He denies any prior abdominal operations. Vital signs include a temperature of $38.5^\circ\text{C}$ ($101.3^\circ\text{F}$), a blood pressure of $96/60\text{ mmHg}$, and a heart rate of $118\text{/min}$. Abdominal examination reveals significant distension, hypoactive bowel sounds, and involuntary guarding. A tense, irreducible $5\text{-cm}$ bulge is noted in the right inguinal region. The skin overlying the bulge is dusky and erythematous. Laboratory studies are significant for a leukocyte count of $18,500\text{/mm}^3$ and a serum lactate of $4.2\text{ mmol/L}$. Which of the following is the most appropriate next step in management?

Match each clinical presentation of an acute surgical abdomen with its most appropriate specific intervention or definitive surgical management.

A 72-year-old woman is evaluated on postoperative day 4 following an open reduction and internal fixation of a right femoral neck fracture. Her medical history includes chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection fraction. On postoperative day 2, she developed a fever of $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$) and a productive cough. A chest radiograph demonstrated a new left lower lobe consolidation. She was empirically started on intravenous vancomycin and cefepime. Today, her fever has resolved, but she reports new-onset orthopnea and worsening shortness of breath over the last 12 hours. Her blood pressure is $135/85\text{ mmHg}$, pulse is $98/\text{min}$, and oxygen saturation is $92\%$ on room air. Physical examination reveals elevated jugular venous pressure and bilateral basilar crackles without wheezing. There is 2+ bilateral lower extremity pitting edema. Sputum cultures from two days ago have finalized, showing heavy growth of Streptococcus pneumoniae that is exquisitely sensitive to ceftriaxone. Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

A 62-year-old man is brought to the emergency department after falling from a 10-foot ladder while cleaning his gutters. He states he was lying on the ground for approximately 12 hours before a neighbor found him. He complains of severe, sharp pain in his right lower chest that significantly worsens when he takes a deep breath. His temperature is 36.8°C (98.2°F), blood pressure is 115/75 mmHg, pulse is 112/min, and respiratory rate is 16/min with shallow breaths. Physical examination reveals bruising and marked point tenderness over the right 7th and 8th ribs. Decreased breath sounds are noted at the right lung base.

Laboratory results are as follows:

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

A 58-year-old man presents to the emergency department with sudden-onset, severe "tearing" chest pain that radiates to his back. His blood pressure is 210/115 mm Hg in his right arm and 175/90 mm Hg in his left arm. His heart rate is 112/min. Physical examination reveals a diastolic decrescendo murmur at the right sternal border. An electrocardiogram shows sinus tachycardia, and a portable chest x-ray reveals a widened mediastinum. The physician suspects an acute aortic dissection.

Arrange the following steps in the most appropriate chronological sequence for the management of this patient.

A 68-year-old man with a history of metastatic prostate cancer is brought to the emergency department due to progressively worsening mid-thoracic back pain, bilateral lower extremity weakness, and new-onset urinary incontinence over the past 48 hours. Neurologic examination reveals $3/5$ motor strength in the lower extremities, hyperreflexia at the knees, and decreased pinprick sensation below the T10 dermatome. Arrange the following management steps in the most appropriate chronological sequence for evaluating and treating this patient's oncologic emergency.

A $74$-year-old woman is brought to the emergency department from a skilled nursing facility due to progressive confusion, shortness of breath, and decreased urine output over the last $48$ hours. She has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, severe chronic obstructive pulmonary disease (COPD), and stage III chronic kidney disease. Her temperature is $36.8^\circ C$ ($98.2^\circ F$), blood pressure is $82/54$ mm Hg, pulse is $118$/min, and respirations are $28$/min. Pulse oximetry shows $85\%$ on room air. Physical examination reveals a lethargic patient in moderate respiratory distress. The jugular venous pressure is estimated at $14$ cm $H_2O$. Chest auscultation reveals bilateral basilar crackles and diffuse expiratory wheezes with a prolonged expiratory phase. Cardiac auscultation reveals a regular tachycardia and a prominent third heart sound (S3). The extremities are cool and mottled, with 2+ bilateral pitting edema extending to the knees. Laboratory studies show a leukocyte count of $11,200$/mm $^3$, a blood urea nitrogen of $48$ mg/dL, and a serum creatinine of $2.3$ mg/dL (baseline $1.4$ mg/dL). An arterial blood gas on room air reveals a pH of $7.22$, $PaCO_2$ of $60$ mm Hg, $PaO_2$ of $50$ mm Hg, and $HCO_3^-$ of $24$ mEq/L. Which of the following is the most appropriate initial management for this patient?

A 68-year-old man is evaluated in the emergency department for a 3-day history of progressively worsening shortness of breath, increased cough, and a change in sputum color from clear to yellow. He has a history of severe chronic obstructive pulmonary disease and primary hypothyroidism. His current medications include an albuterol inhaler as needed and daily levothyroxine. Temperature is 37.7°C (99.9°F), pulse is 105/min, respirations are 24/min, and blood pressure is 140/90 mm Hg. Pulse oximetry shows 89% on room air. Examination shows a prolonged expiratory phase with diffuse expiratory wheezing. Jugular venous pressure is normal, and there is no lower extremity edema. Laboratory studies show a leukocyte count of 9,000/mm³ and a thyroid-stimulating hormone level of 2.5 µU/mL (normal: 0.4–4.0 µU/mL). Arterial blood gas analysis on room air shows a pH of 7.36, PaCO₂ of 52 mm Hg, and HCO₃⁻ of 29 mEq/L. A chest radiograph reveals hyperinflation without focal consolidation or pulmonary vascular congestion. In addition to supplemental oxygen and inhaled short-acting bronchodilators, which of the following is the most appropriate next step in management?

A 54-year-old man is brought to the emergency department by his wife due to worsening confusion and lethargy over the past 48 hours. He has a history of decompensated alcoholic cirrhosis and was recently discharged after treatment for a variceal bleed. His home medications include nadolol, spironolactone, furosemide, and lactulose. The wife reports he has been having 2 to 3 soft bowel movements daily. Temperature is 38.1°C (100.6°F), blood pressure is 105/65 mmHg, pulse is 98/min, and respirations are 18/min. Physical examination reveals scleral icterus and spider angiomas. The abdomen is distended with a positive fluid wave and shifting dullness. There is diffuse, mild abdominal tenderness to palpation without rebound or guarding. Neurologic examination demonstrates asterixis and disorientation to time and place. Laboratory studies show a leukocyte count of 11,500/mm³, a sodium level of 131 mEq/L, and a bicarbonate level of 18 mEq/L. Which of the following is the most appropriate next step in management?