All practice questions

Match each patient presentation describing a suspected tick-borne illness with the most appropriate targeted antimicrobial therapy.

A 73-year-old woman is brought to the emergency department due to a 4-day history of progressively worsening shortness of breath and an increase in the volume and purulence of her sputum. Her medical history includes severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a left ventricular ejection fraction of 35%.

Vital signs are temperature 38.1°C (100.6°F), blood pressure 146/88 mmHg, pulse 112/min, and respirations 28/min. Pulse oximetry shows 87% on room air.

Physical examination shows a patient in respiratory distress using accessory muscles. Jugular venous pressure is estimated at 7 cm H2O. Chest auscultation reveals a prolonged expiratory phase with diffuse polyphonic wheezing. There is no lower extremity edema.

Laboratory studies show:
Leukocyte count: 14,200/mm³
B-type natriuretic peptide: 85 pg/mL

Arterial blood gas (room air):
pH: 7.26
PaCO2: 68 mmHg
PaO2: 50 mmHg
HCO3-: 30 mEq/L

A sputum Gram stain reveals numerous polymorphonuclear leukocytes and gram-negative coccobacilli. She is promptly started on noninvasive positive-pressure ventilation, nebulized ipratropium-albuterol, and intravenous methylprednisolone.

Which of the following is the most appropriate additional pharmacologic intervention for this patient?

A 34-year-old woman arrives at the regional burn center via ambulance after being rescued from a residential house fire. She sustained deep partial-thickness and full-thickness thermal burns. Physical examination reveals that her entire right leg and her entire right arm are burned. Her uninjured skin is intact. The patient weighs $75 \text{ kg}$. The incident occurred exactly $2 \text{ hours}$ prior to her arrival at the hospital. Two large-bore intravenous lines are established.

Using the traditional Parkland formula ($4 \text{ mL/kg/}\% \text{TBSA}$), what should be the initial intravenous fluid infusion rate (in $\text{mL/hr}$) to administer the required volume over the remainder of the first 8 hours post-injury?

Match each clinical and serological laboratory profile to the most appropriate hepatobiliary diagnosis.

A 58-year-old man is evaluated on postoperative day 7 for fever and abdominal pain. He underwent an emergent exploratory laparotomy and partial ileocecal resection for a perforated appendix. His recovery was initially uncomplicated; his urinary catheter was removed on postoperative day 2, and he has been tolerating a soft diet since day 4. Today, he reports nausea, anorexia, and a persistent dull ache in his right lower abdomen. His temperature is 39.2°C (102.6°F), blood pressure is 114/76 mm Hg, pulse is 112/min, and respiratory rate is 18/min. Physical examination reveals a midline surgical incision that is clean, dry, and well-approximated with intact surgical staples. There is no surrounding erythema, induration, or discharge. His abdomen is mildly distended with localized tenderness in the right lower quadrant, but no rebound or guarding is present. Laboratory studies show a leukocyte count of $18,000/\text{mm}^3$. Which of the following is the most appropriate next step in management?

A $52$-year-old woman is evaluated in the clinic due to new-onset palpitations, resting tremor, and heat intolerance over the past four weeks. She also reports a $3$-kg ($6.6$-lb) unintentional weight loss despite maintaining a normal appetite. Her past medical history is unremarkable, and she takes no medications. Vital signs show a temperature of $37.1^\circ$ C ($98.8^\circ$ F), blood pressure of $135/75$ mmHg, and heart rate of $112$/min. Physical examination reveals warm, moist skin, a fine resting tremor in the outstretched hands, and a diffusely enlarged thyroid gland without discrete nodules. Cardiovascular examination confirms a regular tachycardia. No exophthalmos or pretibial myxedema is noted.

Initial laboratory studies show:

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

A $54$-year-old man is evaluated in the hospital on his third day of admission for community-acquired pneumonia. He was initially started on empiric therapy with intravenous ceftriaxone and oral azithromycin. His cough and shortness of breath have significantly improved, and he has been afebrile for the past $24$ hours. He is currently tolerating a regular diet. Sputum cultures collected on admission grew *Streptococcus pneumoniae*. Susceptibility testing reveals that the isolate is susceptible to penicillin, amoxicillin, ceftriaxone, levofloxacin, and vancomycin, and resistant to azithromycin. He has no known drug allergies. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), pulse $76/\text{min}$, respirations $14/\text{min}$, and blood pressure $124/78\text{ mmHg}$. Pulse oximetry is $97\%$ on room air. The patient is being prepared for discharge. Which of the following is the most appropriate antimicrobial regimen to prescribe for this patient upon discharge?

A 68-year-old man with a history of hypertension and type 2 diabetes mellitus presents to the emergency department with palpitations, fatigue, and mild shortness of breath that began 3 days ago. His blood pressure is 125/80 mm Hg, heart rate is 142/min and irregularly irregular, and respiratory rate is 18/min. An electrocardiogram confirms atrial fibrillation with rapid ventricular response. The physician decides to pursue an early rhythm control strategy to alleviate his persistent symptoms.

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

A medical team is reviewing arterial blood gas and basic metabolic panel results for several patients in the intensive care and step-down units. Match each patient's clinical presentation with their most likely primary acid-base disturbance.

A 68-year-old woman is brought to the emergency department by her family due to severe right upper quadrant abdominal pain, worsening jaundice, and shaking chills over the past 24 hours. Her temperature is 39.5°C (103.1°F), blood pressure is 88/54 mmHg, heart rate is 122/min, and respiratory rate is 22/min. She appears lethargic and is oriented only to her name. Physical examination reveals scleral icterus and marked right upper quadrant tenderness with guarding. Laboratory tests show a leukocyte count of 18,000/mm³, total bilirubin of 5.8 mg/dL, and alkaline phosphatase of 410 U/L. Arrange the following interventions in the most appropriate sequential order for the management of this patient.

An emergency medical services team brings a $76$-year-old female resident of a skilled nursing facility to the hospital because of severe respiratory distress that awakened her from sleep. The patient is unable to speak in full sentences and is actively coughing up pink, frothy sputum. Her past medical history is notable for systemic hypertension, osteoarthritis, and a $30$-pack-year history of smoking (quit $15$ years ago). Two weeks ago, she was prescribed daily naproxen for worsening knee pain.

Upon arrival, her temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), blood pressure is $192/108\text{ mmHg}$, heart rate is $118/\text{min}$, and respiratory rate is $30/\text{min}$. Oxygen saturation is $84\%$ on room air.

Physical examination displays prominent use of accessory respiratory muscles. The internal jugular vein is visibly distended while the patient is sitting upright. Chest auscultation reveals diffuse expiratory wheezes and coarse crackles extending halfway up both lung fields. Cardiac examination is significant for a rapid, regular rhythm with a distinct low-frequency sound heard just after $S_2$.

An electrocardiogram shows sinus tachycardia with left ventricular hypertrophy but no acute ischemic changes.

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

A 55-year-old woman arrives at the emergency department reporting a two-day history of progressively worsening, crampy periumbilical pain accompanied by bilious vomiting. She reports an inability to pass flatus or stool for the past 18 hours. Her past medical history is notable for a total abdominal hysterectomy performed eight years ago. Current vital signs are temperature $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure $92/58\text{ mm Hg}$, heart rate $115\text{/min}$, and respiratory rate $20\text{/min}$. Physical examination reveals a significantly distended abdomen with high-pitched bowel sounds. There is marked focal tenderness with voluntary guarding and rebound localized to the left lower quadrant. Laboratory evaluation shows a leukocyte count of $16,800/\mu\text{L}$ and a serum lactate level of $4.1\text{ mmol/L}$. Upright abdominal plain films demonstrate multiple dilated small intestinal loops with prominent air-fluid levels and a paucity of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

A $72$-year-old woman is evaluated in the hospital for sudden-onset shortness of breath and right-sided pleuritic chest pain. She was admitted $3$ days ago for an elective left total hip arthroplasty. Her past medical history is significant for ischemic cardiomyopathy (baseline left ventricular ejection fraction $45\%$), mild chronic obstructive pulmonary disease, and a pituitary macroadenoma treated with transsphenoidal resection $5$ years ago resulting in panhypopituitarism. Her current medications include aspirin, lisinopril, metoprolol succinate, tiotropium, hydrocortisone, and levothyroxine.

Temperature is $37.6^\circ C$ ($99.7^\circ F$), pulse is $118/min$, blood pressure is $132/84$ mm Hg, and respirations are $26/min$. Pulse oximetry shows $88\%$ on room air. Physical examination reveals clear lungs to auscultation bilaterally. The jugular venous pressure is $9$ cm $H_2O$. The right calf is swollen, erythematous, and tender to palpation.

Laboratory results are as follows:
Leukocyte count: $9,500/mm^3$
Thyroid-stimulating hormone (TSH): $1.1 \mu U/mL$ (Normal: $0.4-4.0 \mu U/mL$)
Free thyroxine (T4): $0.6 ng/dL$ (Normal: $0.9-1.7 ng/dL$)

Arterial blood gas on room air:
pH: $7.50$
$PaCO_2$: $28$ mm Hg
$PaO_2$: $56$ mm Hg
$HCO_3^-$: $22 mEq/L$

An electrocardiogram shows sinus tachycardia with a prominent S wave in lead I, a Q wave in lead III, and an inverted T wave in lead III.

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

Match the following structural heart pathologies with their characteristic auscultatory findings and their specific responses to physiological maneuvers.

A $58$-year-old woman is mechanically ventilated in the intensive care unit for acute respiratory distress syndrome (ARDS) secondary to severe pneumonia. She has shown significant clinical improvement over the past $48$ hours. Arrange the following steps in the standard, evidence-based sequential order for assessing readiness and executing liberation from mechanical ventilation.

A 74-year-old man is hospitalized for symptomatic anemia secondary to newly diagnosed myelodysplastic syndrome. His medical history includes chronic obstructive pulmonary disease (COPD) and essential hypertension. His pre-transfusion hemoglobin is 6.1 g/dL.

A transfusion of two units of packed red blood cells is ordered. Thirty minutes into the transfusion of the second unit, the patient reports acute-onset shortness of breath and a dry cough. A urine culture sent on admission for mild dysuria has just resulted, showing >100,000 CFU/mL of *Escherichia coli* that is susceptible to nitrofurantoin and cephalexin, but resistant to ciprofloxacin.

Temperature is 37.1°C (98.8°F), blood pressure is 185/95 mm Hg, pulse is 112/min, and respirations are 28/min. Pulse oximetry shows an oxygen saturation of 85% on room air. Physical examination reveals prominent jugular venous distention. Cardiac examination shows regular tachycardia with a loud S3 gallop. Pulmonary examination reveals bilateral crackles extending halfway up the lung fields, with scattered expiratory wheezes.

Arterial blood gas analysis on room air shows:

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

A 42-year-old woman is evaluated in the post-anesthesia care unit 3 hours after undergoing a total thyroidectomy for a multinodular goiter. The nurse calls for assistance because the patient has developed sudden, progressive difficulty breathing. On physical examination, the patient is agitated and diaphoretic. Her blood pressure is 145/90 mm Hg, pulse is 115/min, and respiratory rate is 26/min. Oxygen saturation is 88% on room air. High-pitched inspiratory stridor is audible. The anterior neck reveals a tense, rapidly expanding, firm swelling beneath the surgical incision. Arrange the following steps in the most appropriate chronological order for managing this patient's condition.

Match each patient's serum and urine laboratory profile with the most likely underlying diagnosis. Assume all patients have a normal clinical volume status (euvolemia) unless otherwise implied by the laboratory values.

A $24$-year-old male presents to the clinic with a $3$-day history of severe abdominal cramping and diarrhea. He reports that the diarrhea was initially watery but has become frankly bloody over the past $24$ hours. He has not traveled recently but frequently eats at a local food truck that serves hamburgers. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $112/74\text{ mm Hg}$, and pulse is $92\text{/min}$. Physical examination reveals a non-distended abdomen with moderate, diffuse tenderness to palpation, but no rebound or guarding. Bowel sounds are hyperactive. Laboratory studies show a leukocyte count of $9,500/\text{mm}^3$, hemoglobin of $13.8\text{ g/dL}$, and a platelet count of $185,000/\text{mm}^3$. Renal function panel is currently within normal limits. Stool testing for ova and parasites is negative, and stool culture is pending. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation of chronic gastrointestinal dysfunction with the most accurate underlying pathophysiologic mechanism or etiology.