All practice questions

A 24-year-old man is brought to the emergency department 15 minutes after sustaining a gunshot wound. The entrance wound is located in the left fifth intercostal space at the midclavicular line. There is no exit wound.

Vital signs on arrival:
- Blood pressure: 76/40 mm Hg
- Heart rate: 138/min
- Respiratory rate: 32/min
- Oxygen saturation: 86% on room air

Primary survey reveals flat neck veins and a midline trachea. There are absent breath sounds and dullness to percussion over the left hemithorax. The abdomen is exquisitely tender with diffuse rigidity and involuntary guarding.

Large-bore intravenous access is established, the massive transfusion protocol is activated, and the patient is rapidly intubated for airway protection. His blood pressure remains 76/40 mm Hg following intubation.

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

A 35-year-old woman is brought to the emergency department by emergency medical services after collapsing at a local seafood restaurant. Bystanders report that shortly after she began eating, she grasped her throat, developed a hoarse voice, and subsequently lost consciousness. Her past medical history is significant for poorly controlled asthma and allergic rhinitis, for which she uses an inhaled corticosteroid and a short-acting beta-agonist as needed.

Upon arrival, she is unresponsive to verbal stimuli but withdraws from painful stimuli.

Vital signs are:
Temperature: 37.1°C (98.8°F)
Blood pressure: 72/40 mmHg
Heart rate: 138/min
Respiratory rate: 32/min
Oxygen saturation: 84% on a non-rebreather mask

Physical examination reveals significant facial and periorbital edema. Lung auscultation demonstrates poor air movement bilaterally with prominent high-pitched inspiratory stridor and diffuse expiratory wheezes. Examination of the skin shows widespread raised, erythematous, intensely pruritic plaques across her trunk and extremities.

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

A $54$-year-old woman is evaluated in the ambulatory care clinic and diagnosed with primary hypertension. Her blood pressure is $154/92\text{ mmHg}$. She has no other chronic medical conditions and takes no daily medications. Baseline laboratory studies reveal a creatinine level of $0.9\text{ mg/dL}$ and a potassium level of $4.1\text{ mEq/L}$. The physician initiates once-daily oral lisinopril. The patient is scheduled for a follow-up appointment.

Which of the following is the most appropriate next step in monitoring this patient's new pharmacotherapy?

A 32-year-old man is evaluated in the outpatient clinic for increased thirst and frequent urination over the past 3 months. He reports drinking approximately 6 to 8 liters of water daily and waking up 3 to 4 times per night to urinate. His medical history is significant for bipolar I disorder. He has had multiple severe manic episodes with psychotic features in the past, which required prolonged hospitalizations. Trials of divalproex sodium, carbamazepine, and atypical antipsychotics were ineffective in preventing relapses. For the past 4 years, he has been completely stable with no mood episodes on a regimen of lithium carbonate $900 \text{ mg}$ daily. He takes no other medications.

Vital signs are within normal limits. Physical examination reveals mild dry mucous membranes but is otherwise unremarkable.

Laboratory results are as follows:
Serum sodium: $146 \text{ mEq/L}$
Serum potassium: $4.1 \text{ mEq/L}$
Serum creatinine: $1.0 \text{ mg/dL}$
Serum lithium: $0.9 \text{ mEq/L}$ (therapeutic range: $0.6-1.2 \text{ mEq/L}$)
Serum osmolality: $298 \text{ mOsm/kg H}_2\text{O}$
Urine osmolality: $120 \text{ mOsm/kg H}_2\text{O}$

Following a formal water deprivation test, his urine osmolality remains low and does not significantly increase after the administration of subcutaneous desmopressin.

Given the patient's psychiatric history and current stability, which of the following is the most appropriate next step in the management of this patient's new symptoms?

A 42-year-old man presents to the urgent care clinic with a 3-day history of fever, productive cough, and shortness of breath. He has a history of type 2 diabetes mellitus and takes metformin. Vital signs are temperature 38.4°C (101.1°F), blood pressure 125/80 mmHg, pulse 98/min, and respiratory rate 20/min. Oxygen saturation is 96% on room air. Physical examination reveals crackles in the left lower lung base. Laboratory studies show a leukocyte count of 11,500/mm³ with 75% neutrophils. A chest x-ray reveals a left lower lobe infiltrate. The patient reports a history of severe anaphylaxis to penicillin, characterized by hives and wheezing. He has not taken any antibiotics in the past 90 days. Which of the following is the most appropriate empiric pharmacologic intervention for this patient?

A 68-year-old man is evaluated in the intensive care unit for sudden-onset shortness of breath and right-sided pleuritic chest pain. Three days ago, he underwent a left frontotemporal craniotomy for resection of a glioblastoma. His temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, pulse is 112/min, and respirations are 24/min. Pulse oximetry shows 91% on room air. Physical examination reveals a well-healing cranial incision. The lungs are clear to auscultation bilaterally. Laboratory studies show a troponin I level of 0.8 ng/mL (normal: $<0.04$ ng/mL). A computed tomography pulmonary angiogram demonstrates a large filling defect in the right main pulmonary artery with associated right ventricular enlargement. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old woman presents to the clinic for a routine health maintenance visit. Six months ago, she was diagnosed with Crohn disease involving the terminal ileum and colon. Her disease is currently in clinical remission on a maintenance regimen of infliximab and azathioprine. She feels well and reports no abdominal pain, diarrhea, or weight loss. She works as a high school teacher. Review of her immunization records reveals she received all standard childhood vaccines but has not received any immunizations since age 18. Laboratory evaluation shows negative varicella-zoster virus IgG antibodies. Her vital signs and physical examination today are unremarkable. Which of the following is the most appropriate next step in the preventive management of this patient?

A 42-year-old man is being prepared for discharge after a 28-day hospital course for severe acute necrotizing pancreatitis complicated by infected pseudocysts. He underwent multiple exploratory laparotomies and abdominal washouts. He is now afebrile, tolerating a transitional oral diet, and his open abdominal wounds are healing well via secondary intention, though they require daily complex dressing changes. The multidisciplinary team determines he is stable to be discharged to his private residence with support from a Home Health Agency (HHA) for wound care and outpatient parenteral antimicrobial therapy (OPAT).

Arrange the following steps of the hospital discharge and care transition process in the most appropriate chronological sequence to ensure patient safety and minimize the risk of readmission.

An internal medicine physician is coordinating the care transition for a 69-year-old woman on hospital day 6. She was initially hospitalized for sepsis secondary to a complicated urinary tract infection. Her clinical course included a three-day intensive care unit stay requiring vasopressor support. She has since been successfully stepped down to the general medical floor, and her infection has clinically resolved on targeted oral antibiotic therapy. She has a history of diet-controlled type 2 diabetes mellitus and moderate osteoarthritis of the knees.

Her vital signs are now stable and within normal limits. A multidisciplinary evaluation notes that she requires moderate physical assistance from one person to transfer from a bed to a chair and to walk short distances. During daily sessions with physical and occupational therapy, the patient becomes visibly exhausted and cannot participate in therapeutic exercises for more than 45 minutes total per day.

Before her illness, she lived independently in a single-story house. Her only relative is a son who lives in a neighboring state and is unable to provide physical assistance or stay with her.

Based on her clinical and functional status, which of the following is the most appropriate next step in care transition for this patient?

A 78-year-old woman is evaluated on hospital day 7 for disposition planning. She was admitted for an acute right middle cerebral artery territory ischemic stroke. Her hospital course was complicated by mild aspiration pneumonia, which has been fully treated with a 5-day course of intravenous antibiotics.

Her past medical history includes hypertension, vascular dementia, and severe oropharyngeal dysphagia. A percutaneous endoscopic gastrostomy (PEG) tube was placed two years ago, and her enteral feeding regimen is well-tolerated and stable.

Currently, she is afebrile and medically stable with vital signs within normal limits. She is breathing comfortably on room air.

Neurologic examination shows dense left-sided hemiplegia, profound left-sided neglect, and expressive aphasia. She is bedbound and requires maximal assistance from two caregivers for all activities of daily living (ADLs), including bed mobility, transfers, and personal hygiene. She is unable to follow multi-step commands and cannot actively participate in physical or occupational therapy sessions.

The patient lives with her 82-year-old husband, who has advanced Parkinson disease and relies on a motorized wheelchair. He is her designated healthcare proxy and states he can no longer physically care for her at home. He is fully cooperative with the medical team's recommendations. They have no other local family support.

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

A 48-year-old man presents to the primary care clinic reporting worsening fatigue, excessive sweating, and joint pain in his knees and hands over the past year. He mentions that his wedding ring no longer fits and he recently had to purchase shoes two sizes larger than his usual size. He has a history of newly diagnosed hypertension and obstructive sleep apnea. Vital signs show a blood pressure of 152/94 mm Hg, heart rate of 76/min, and respiratory rate of 14/min. Physical examination reveals coarse facial features, a prominent mandible, macroglossia, and enlarged, doughy hands. Visual field testing by confrontation is normal. A serum insulin-like growth factor-1 (IGF-1) level is ordered and returns markedly elevated for his age and sex. Which of the following is the most appropriate next step in the patient's diagnostic workup?

A 62-year-old woman presents to the outpatient clinic with a 4-day history of intense vulvar pruritus, dysuria, and a thick, white, odorless vaginal discharge. Her medical history is significant for a mechanical mitral valve replacement 5 years ago, for which she takes daily warfarin. Her other medications include metoprolol and low-dose aspirin. Her last international normalized ratio (INR) obtained one week ago was 2.8, which is within her target range of 2.5 to 3.5. Vital signs are within normal limits. Pelvic examination reveals significant vulvovaginal erythema and thick, adherent white plaques on the vaginal walls. A potassium hydroxide (KOH) preparation of the vaginal discharge reveals branching pseudohyphae and budding yeast. Which of the following is the most appropriate pharmacologic intervention for this patient?

A 67-year-old man is evaluated in the emergency department for sudden-onset, severe, tearing pain between his shoulder blades that began two hours ago. He has a history of poorly controlled hypertension, hyperlipidemia, and a 40-pack-year smoking history. On presentation, his blood pressure is 218/114 mmHg in the right arm and 212/110 mmHg in the left arm, and his heart rate is 112/min. Physical examination reveals a distressed, diaphoretic patient. Cardiovascular examination shows a regular rhythm with no murmurs. Abdominal examination reveals diffuse tenderness with voluntary guarding and diminished bowel sounds. The right lower extremity is cool to the touch with absent dorsalis pedis and posterior tibial pulses; left lower extremity pulses are normal. Initial laboratory studies show a serum lactate level of 5.8 mmol/L and a serum creatinine of 2.1 mg/dL (baseline 1.0 mg/dL). Intravenous esmolol and nicardipine infusions are initiated, successfully lowering his blood pressure to 118/74 mmHg and heart rate to 62/min. A computed tomography angiography of the chest, abdomen, and pelvis demonstrates an intimal flap originating just distal to the left subclavian artery and extending into the common iliac arteries. The true lumen is severely compressed by the false lumen. The superior mesenteric and right renal arteries arise from the false lumen, which exhibits delayed and sluggish contrast enhancement. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old woman schedules a telehealth consultation to establish primary care after moving to a new state. She reports feeling well and takes only a daily multivitamin. She underwent menopause at age 51. She has never used tobacco products, drinks alcohol occasionally, and walks two miles daily. Her family history is notable for hypertension in her father. She reports her last colonoscopy was at age 62 and was normal, and her last mammogram was six months ago and normal. Which of the following screening tests is most appropriate to order for this patient today?

A psychiatrist is evaluating a 31-year-old male patient who recently experienced a severe acute manic episode. The physician decides to initiate pharmacotherapy with valproate as a mood stabilizer. Before starting this medication and periodically during the initial months of treatment, specific laboratory parameters must be monitored due to the drug's known adverse effect profile. Which of the following diagnostic studies should be routinely obtained for this patient? (Select all that apply)

A physician is reviewing the laboratory results of a 64-year-old woman who had blood drawn earlier in the day for routine monitoring. The patient has a history of rheumatic heart disease and underwent a mechanical mitral valve replacement four years ago. She is maintained on chronic warfarin therapy. Three days ago, she was evaluated at an urgent care clinic for dysuria and was prescribed a short course of trimethoprim-sulfamethoxazole. During a subsequent telephone encounter, the patient reports feeling well and denies any bruising, bleeding gums, epistaxis, or dark stools. Her target international normalized ratio (INR) is 2.5 to 3.5. Today, her INR is reported as 7.2. Which of the following is the most appropriate next step in the management of this patient's anticoagulation?

A $38$-year-old man presents to the clinic for a follow-up evaluation of worsening fatigue, a $6\text{-kg}$ ($13.2\text{-lb}$) weight gain, and easy bruising over the past $3$ months. He also reports new-onset muscle weakness when climbing stairs. His medical history is significant for HIV, diagnosed $4$ years ago, and severe seasonal allergic rhinitis. His current medications include a single-tablet antiretroviral regimen consisting of elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide. Four months ago, he was prescribed a fluticasone nasal spray for his allergic rhinitis, which he uses twice daily.

Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $158/96 \text{ mmHg}$, pulse $82\text{/min}$, and respirations $14\text{/min}$. BMI is $31 \text{ kg/m}^2$. Physical examination reveals a plethoric face, prominent supraclavicular fat pads, and wide violaceous striae on the lower abdomen.

Laboratory studies:
Sodium: $142 \text{ mEq/L}$
Potassium: $3.8 \text{ mEq/L}$
Fasting glucose: $135 \text{ mg/dL}$
Morning serum cortisol: $1.2 \text{ \mu g/dL}$ (Normal: $6\text{--}23 \text{ \mu g/dL}$)
Plasma ACTH: $< 5 \text{ pg/mL}$ (Normal: $10\text{--}60 \text{ pg/mL}$)
HIV viral load: Undetectable
CD4 T-lymphocyte count: $620\text{/mm}^3$

What is the most appropriate next step in the pharmacologic management of this patient?

A 48-year-old male construction worker visits a primary care clinic to establish care. He states that he feels entirely healthy and has avoided the medical system for over twenty years. He currently smokes one pack of cigarettes daily and has maintained this habit since his early twenties. He is in a monogamous relationship with a new female partner. Vital signs are within normal limits, and his body mass index is 23 kg/m². He has no family history of malignancy or premature cardiovascular disease. Based on current evidence-based guidelines, which of the following preventive screening tests should be ordered for this patient today? (Select all that apply)

A 49-year-old premenopausal female is evaluated in the medical oncology clinic to discuss adjuvant therapy following a recent lumpectomy and sentinel lymph node biopsy. Pathology demonstrated a 1.5-cm, estrogen receptor-positive, progesterone receptor-positive, and HER2-negative invasive ductal carcinoma. Margins were negative, and no lymph nodes were involved. She completed adjuvant radiation therapy last week and is now scheduled to begin endocrine therapy. Her past medical history includes major depressive disorder, which has been well-controlled on paroxetine for the past 4 years. She currently reports no depressive symptoms but complains of moderate daily hot flashes. Vital signs and physical examination are unremarkable. The oncologist plans to start tamoxifen. Which of the following is the most appropriate recommendation regarding this patient's pharmacotherapy?

Determine the most appropriate post-acute care disposition for each patient based on their clinical stability, functional status, and required level of ongoing medical intervention.