All practice questions

A $26$-year-old female patient is evaluated in the intensive care unit on postoperative day $4$ following a right total hip arthroplasty. Her past medical history is significant for Adult-Onset Still's disease, for which she is chronically managed with methotrexate and tocilizumab. She has developed acute lethargy, confusion, and a temperature of $39.9^\circ\text{C}$ ($103.8^\circ\text{F}$).

Physical examination reveals a blood pressure of $90/55 \text{ mmHg}$, heart rate of $132/\text{min}$, and respiratory rate of $26/\text{min}$. The surgical incision is clean, dry, and without erythema or fluctuance. Pulmonary and cardiac examinations are unremarkable. Abdominal examination reveals hepatosplenomegaly.

Laboratory studies are as follows:

Arterial blood gas (room air) shows $\text{pH}$ $7.52$, $\text{pCO}_2$ $26 \text{ mmHg}$, $\text{pO}_2$ $88 \text{ mmHg}$, and $\text{HCO}_3^-$ $21 \text{ mEq/L}$.

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

A 75-year-old man is brought to the emergency department for severe shortness of breath and worsening confusion over the past 24 hours. He has a history of severe chronic obstructive pulmonary disease, heart failure with preserved ejection fraction, and hypothyroidism. His medications include tiotropium, salmeterol, levothyroxine, and low-dose furosemide.

Temperature is 38.6°C (101.5°F), blood pressure is 92/58 mm Hg, pulse is 118/min, and respiratory rate is 26/min. Pulse oximetry shows 86% on room air. On examination, the patient is lethargic and oriented only to person. Jugular venous pressure is 5 cm H₂O. Chest auscultation reveals crackles in the left lower lung field and diffuse expiratory wheezing. Heart sounds are tachycardic but regular. The extremities are warm with brisk capillary refill, and there is no peripheral edema.

Laboratory results:
Sodium: 135 mEq/L
Potassium: 4.5 mEq/L
Chloride: 98 mEq/L
Bicarbonate: 12 mEq/L
Blood urea nitrogen: 48 mg/dL
Serum creatinine: 2.3 mg/dL
Serum lactate: 6.2 mmol/L
Leukocyte count: 18,500/mm³
TSH: 0.1 µU/mL (Normal: 0.4-4.0 µU/mL)
Free T4: 1.1 ng/dL (Normal: 0.9-1.7 ng/dL)

Arterial blood gas on room air:
pH: 7.18
PaCO₂: 33 mm Hg
PaO₂: 58 mm Hg

Chest radiograph shows a left lower lobe consolidation. A rapid multiplex PCR panel of a tracheal aspirate is positive for *Streptococcus pneumoniae* and negative for all common resistance genes.

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

A 4-year-old girl is brought to the clinic by her father for a scheduled well-child visit. She was born at 32 weeks gestation following an uncomplicated pregnancy. The father expresses several concerns regarding his daughter's development and physical findings. He notes that she frequently repeats syllables when she is excited to tell a story. He is also worried because she firmly believes a "monster" lives in her closet and refuses to sleep without a nightlight. Additionally, he reports she is unable to tie her own shoelaces.

During the examination room observation, the girl is seen hopping on one foot and playing a turn-taking board game with her father. When handed paper and crayons, she successfully copies a cross and draws a person with three body parts, but she is unable to copy a triangle.

Physical examination reveals a temperature of 37.1°C (98.8°F), heart rate of 102/min, and blood pressure of 90/55 mm Hg. When she stands with her legs straight and knees gently touching, the distance between her medial malleoli is measured at 5 cm (2 in). Cardiac auscultation reveals a grade 2/6, low-pitched, vibratory systolic ejection murmur at the left lower sternal border that becomes significantly softer when the patient transitions from a supine to a standing position.

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

A 24-month-old boy is brought to the clinic by his parents for a routine well-child visit. His parents express concern regarding his development. They report that he frequently refuses to share toys with his older sister and prefers to play alongside her rather than together. Furthermore, they are worried because he cannot pedal the tricycle he received for his second birthday. On physical examination, the child runs well and walks up and down the examination room steps by placing both feet on each step. He is able to kick a ball forward. During the visit, he stacks 6 wooden blocks to build a tower. His vocabulary consists of approximately 50 words, and he uses 2-word phrases. His speech is roughly 50% intelligible to the physician. Which of the following is the most appropriate next step in management?

Match each of the following patient vignettes, representing complex hemostatic disruptions, to the most accurate underlying pathophysiologic mechanism or diagnosis.

Match each clinical scenario describing a recent infectious exposure or early clinical presentation with the most appropriate targeted empiric therapy or post-exposure prophylaxis.

During multidisciplinary rounds in the intensive care unit, a clinical pharmacist raises a concern regarding a patient being treated for infective endocarditis. The patient was admitted 8 days ago after presenting with a one-month history of fatigue, low-grade fevers, and painful, erythematous nodules on the distal fingers. Initial blood cultures grew *Enterococcus faecalis* that was widely susceptible, including to ampicillin, vancomycin, and high-level gentamicin. Echocardiography confirmed a 1.2-cm vegetation on the native mitral valve. The patient was promptly started on intravenous ampicillin and scheduled doses of intravenous gentamicin. Today, the patient is afebrile and hemodynamically stable. However, routine laboratory studies reveal a serum creatinine level of 2.6 mg/dL, an increase from 0.8 mg/dL on admission. Urinalysis demonstrates muddy brown casts. Which of the following is the most appropriate modification to this patient's pharmacotherapy?

A $28$-year-old woman presents to the clinic complaining of worsening fatigue, exertional dyspnea, and yellowing of her eyes over the past two weeks. Her past medical history is significant for systemic lupus erythematosus (SLE), which has been well-controlled on hydroxychloroquine. Vital signs are within normal limits except for a heart rate of $112$/min. Physical examination reveals scleral icterus and pale conjunctivae. The spleen is palpable $3$ cm below the left costal margin. Laboratory studies reveal the following:

A peripheral blood smear demonstrates normochromic red blood cells, marked polychromasia, and numerous spherocytes. No schistocytes are seen. Which of the following is the most appropriate next step to establish the diagnosis?

A $22$-year-old man with type $1$ diabetes mellitus is brought to the emergency department with a $2$-day history of nausea, vomiting, and abdominal pain. He recently had a respiratory infection and missed his last several doses of insulin. On presentation, he is lethargic. Vital signs show a heart rate of $122/\text{min}$, blood pressure of $90/60 \text{ mm Hg}$, and respiratory rate of $28/\text{min}$ with deep, rapid breaths. Laboratory studies reveal:

- Serum glucose: $480 \text{ mg/dL}$
- Serum sodium: $132 \text{ mEq/L}$
- Serum bicarbonate: $12 \text{ mEq/L}$
- Arterial pH: $7.15$
- Urinalysis: $+++$ ketones

A complete metabolic panel has been drawn, but the serum potassium result is currently pending.

Arrange the following critical steps in the management of this patient's diabetic ketoacidosis in the correct sequential order.

A 34-year-old woman is evaluated in the outpatient clinic for progressive fatigue, a $4.5\text{ kg}$ ($10\text{ lb}$) weight gain, and feeling persistently cold over the past 8 months. She also reports that she has not resumed menstruating since giving birth to her third child 14 months ago. The delivery was complicated by severe postpartum hemorrhage requiring emergent blood transfusions. Her blood pressure is $92/58\text{ mm Hg}$, and her pulse is $54/\text{min}$. Physical examination reveals pale, dry skin and a delayed relaxation phase of the deep tendon reflexes.

Laboratory studies:
- Sodium: $132\text{ mEq/L}$
- Potassium: $4.2\text{ mEq/L}$
- Thyroid-stimulating hormone (TSH): $1.6\ \mu\text{U/mL}$ (normal: $0.5-5.0\ \mu\text{U/mL}$)
- Free thyroxine (T4): $0.3\text{ ng/dL}$ (normal: $0.9-1.7\text{ ng/dL}$)

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

A mother brings her 12-month-old boy to the clinic for a routine well-child visit. He was born at 28 weeks of gestation via emergency cesarean delivery due to severe maternal preeclampsia. He spent 6 weeks in the neonatal intensive care unit primarily for respiratory distress syndrome but was discharged on room air and has since done well. Today, the mother expresses deep concern regarding his neurodevelopment. She notes that her older daughter was walking independently and saying specific words like 'dog' and 'milk' by her first birthday. In contrast, her son currently only pulls himself up to a standing position while holding onto furniture and babbles 'mamama' and 'bababa' without directing it at anyone specifically. On physical examination, the infant sits steadily without support and transitions smoothly from lying down to a seated position. He transfers a wooden block from one hand to the other and picks up a small piece of cereal using his thumb along with his index and middle fingers. When the physician covers a small toy with a towel, the infant immediately pulls the towel away to retrieve it. Muscle tone and deep tendon reflexes are normal throughout. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old man presents to the university health clinic with a 2-day history of fever, severe sore throat, and painful swallowing. He reports no cough, rhinorrhea, or hoarseness. His temperature is 38.6°C (101.5°F), blood pressure is 118/76 mm Hg, and pulse is 98/min. Physical examination reveals enlarged, erythematous tonsils with whitish exudates and bilateral tender anterior cervical lymphadenopathy. A rapid antigen detection test for Group A *Streptococcus* is positive. The patient has no known drug allergies. Which of the following is the most appropriate antibiotic regimen?

Match the following developmental milestone clusters with the age at which a typically developing child is expected to achieve them.

A 15-month-old girl is brought to the clinic for a routine well-child visit. She was born at 28 weeks gestation due to severe maternal preeclampsia. She spent two months in the neonatal intensive care unit primarily for respiratory support and feeding optimization, but was discharged without major complications. Her parents are anxious about her development, noting that her 15-month-old cousin is already walking independently and speaking several words.

On examination, the patient is alert and interactive. She can pull herself to a stand and cruises along the examination table, but she does not take independent steps. She uses a neat pincer grasp to pick up a small cereal piece. She says "mama" and "dada" specifically to her parents and points to a toy stethoscope she wants. She readily plays peek-a-boo with the physician. Neurologic examination reveals normal muscle tone, 2+ symmetric deep tendon reflexes, and no cranial nerve deficits. Growth parameters (adjusted for prematurity) are tracking along the 50th percentiles.

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

A $72$-year-old man presents to the emergency department with a $3$-day history of progressively worsening shortness of breath. He reports that his breathing becomes particularly difficult when he lies down, forcing him to sleep in a recliner chair for the past two nights. His medical history is significant for moderate chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, hypertension, and a myocardial infarction $3$ years ago. His current medications include an albuterol inhaler, metformin, lisinopril, and metoprolol. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $168/94\text{ mm Hg}$, pulse is $108/\text{min}$ and regular, and respirations are $26/\text{min}$. Pulse oximetry shows $86\%$ on room air. Jugular venous pressure is estimated at $12\text{ cm H}_2\text{O}$. Chest auscultation reveals diffuse bilateral wheezing with a markedly prolonged expiratory phase; no focal crackles are heard. Cardiac auscultation reveals distant heart sounds, but a faint third heart sound (S3) is appreciated at the apex. Bilateral $2+$ pitting edema is present up to the mid-calves.

Laboratory results are as follows:
Sodium: $136\text{ mEq/L}$
Potassium: $4.0\text{ mEq/L}$
Chloride: $100\text{ mEq/L}$
Bicarbonate: $24\text{ mEq/L}$
Blood urea nitrogen: $25\text{ mg/dL}$
Serum creatinine: $1.2\text{ mg/dL}$
Thyroid-stimulating hormone (TSH): $6.5\text{ }\mu\text{U/mL}$ (Normal: $0.4-4.0$)
Free T4: $1.1\text{ ng/dL}$ (Normal: $0.9-1.7$)

Arterial blood gas (room air):
pH: $7.26$
$\text{PaCO}_2$: $58\text{ mm Hg}$
$\text{PaO}_2$: $54\text{ mm Hg}$

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

A 55-year-old woman is evaluated in the hospital on day 2 of admission for uncomplicated community-acquired pneumonia. She was initially started on intravenous ceftriaxone and azithromycin. Over the past 48 hours, her temperature has normalized from an admission peak of 38.9°C (102.0°F) to 37.2°C (99.0°F), and her respiratory effort has markedly improved. Two sets of peripheral blood cultures (four bottles total) were obtained in the emergency department prior to antibiotic administration. Today, the laboratory reports that one aerobic bottle from the first set is growing Staphylococcus epidermidis. The other three bottles exhibit no growth after 48 hours of incubation. The patient has no indwelling vascular catheters or prosthetic devices. Upon receiving the culture report, the cross-covering physician immediately adds intravenous vancomycin to the patient's regimen. Which of the following is the most appropriate next step in the management of this patient's pharmacotherapy?

A 65-year-old man is evaluated in the general internal medicine clinic prior to an elective colonoscopy with planned polypectomy. He has a history of a mechanical mitral valve replacement and takes warfarin daily. His target international normalized ratio (INR) is 2.5 to 3.5. The patient is considered to be at high risk for thromboembolism, and bridging therapy is indicated.

Arrange the following steps for periprocedural anticoagulation management in the correct chronological sequence.

A 15-month-old boy is brought to the clinic for a routine well-child evaluation. His parents are anxious because his growth percentiles have 'dropped' over the past several months, and they are concerned he may have a developmental delay because he is not yet running or climbing stairs. The boy was born at 39 weeks gestation following an uncomplicated pregnancy. His birth weight was 3.9 kg (85th percentile) and length was 52 cm (90th percentile). His mother's height is 152 cm (5 ft 0 in) and his father's height is 163 cm (5 ft 4 in). Review of the boy's growth chart shows that he tracked along the 85th percentile for both weight and length until 4 months of age. Since 6 months of age, his weight and length have gradually crossed percentiles downward concurrently. Today, his weight is 9.5 kg (25th percentile) and length is 76 cm (25th percentile). His head circumference has consistently tracked along the 50th percentile since birth. His diet consists of a variety of table foods, 16 oz of whole milk daily, and water. He has 1 to 2 soft bowel movements daily. On developmental assessment, he walks independently, uses a neat pincer grasp, drinks from a cup, and stacks 2 blocks. He says 'mama' and 'dada' specifically, uses 3 additional words consistently, and points to objects he wants. Physical examination shows a healthy-appearing boy with normal muscle tone. Which of the following is the most appropriate next step in management?

A 72-year-old man is brought to the emergency department by his daughter due to worsening confusion, dizziness, and recurrent spontaneous epistaxis over the past 48 hours. He also reports that his vision has become increasingly blurred. His medical history is notable for hypertension and mild chronic obstructive pulmonary disease. On physical examination, temperature is $37.2^\circ \text{C}$ ($99.0^\circ \text{F}$), blood pressure is 145/88 mmHg, pulse is 92/min, and respirations are 16/min. Funduscopic examination reveals bilateral retinal hemorrhages and prominently dilated, tortuous retinal veins. Cardiopulmonary examination is unremarkable. Abdominal examination demonstrates a palpable spleen tip 4 cm below the left costal margin.

Laboratory evaluation shows:

Serum protein electrophoresis demonstrates a large monoclonal spike in the gamma region. Subsequent immunofixation confirms the presence of an IgM monoclonal protein.

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

A 4-year-old boy is brought to the clinic for a well-child visit. Three months ago, he was diagnosed with minimal change disease. He experienced a relapse one month ago and has been taking oral prednisone at a dose of $2 \text{ mg/kg/day}$ for the past four weeks. His blood pressure is normal, and a physical examination shows resolving periorbital edema. The parents note he is due for his routine pre-kindergarten vaccinations and ask if they can be administered today. Which of the following vaccines must be withheld from this patient at this visit?