All practice questions

A 23-year-old female college student presents to the university health clinic for a routine wellness examination. She reports feeling well and has no specific complaints. Her medical history is unremarkable, and she currently takes an oral contraceptive pill daily. She mentions that she recently became sexually active with a new male partner. Review of her immunization records confirms she completed the human papillomavirus (HPV) vaccine series at age 12. According to current United States Preventive Services Task Force (USPSTF) guidelines, which of the following screening interventions are indicated for this patient during today's visit? (Select all that apply)

A 68-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) is being prepared for hospital discharge following an acute exacerbation. He initially presented with hypoxemic respiratory failure requiring noninvasive positive pressure ventilation. He has since improved and will be discharged on continuous home oxygen therapy, which is a new requirement for him. He also has a newly prescribed inhaler regimen. To ensure a safe transition of care and minimize readmission risk, arrange the following discharge planning steps in the most appropriate chronological sequence.

A 42-year-old man presents to the emergency department with sudden-onset shortness of breath and right-sided pleuritic chest pain. He has a history of focal onset seizures, which have been well controlled on carbamazepine for the past five years. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $132/84\text{ mm Hg}$, heart rate $105/\text{min}$, respiratory rate $20/\text{min}$, and oxygen saturation $95\%$ on room air. Physical examination reveals clear lungs and a swollen, tender right calf. A computed tomography pulmonary angiogram reveals a segmental pulmonary embolism in the right lower lobe. Laboratory studies reveal a serum creatinine of $0.9\text{ mg/dL}$ and normal hepatic function. Which of the following is the most appropriate pharmacologic intervention for this patient?

Paramedics transport an $82$-year-old female to the acute care area following a syncopal episode at her residence. Her family reports she complained of severe dizziness and chest heaviness immediately before losing consciousness. Her medical history is significant for hypertension, hyperlipidemia, and a myocardial infarction three years ago. Upon arrival, the patient is lethargic and profoundly diaphoretic. Vital signs show a temperature of $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$), blood pressure of $72/40\text{ mmHg}$, pulse of $28/\text{min}$, and respiratory rate of $18/\text{min}$. Oxygen saturation is $94\%$ on room air. Physical examination reveals cool, clammy extremities with a capillary refill time of $4\text{ seconds}$. Jugular venous distention is absent, and lung fields are clear to auscultation bilaterally. A $12$-lead electrocardiogram displays regular P waves at a rate of $90/\text{min}$ and regular, broad QRS complexes ($0.16\text{ sec}$) at a rate of $28/\text{min}$ with complete dissociation between the atria and ventricles. Two large-bore intravenous lines are secured. Which of the following is the most appropriate next step in the stabilization of this patient?

A $54$-year-old man with a history of stage $4$ chronic kidney disease presents to the emergency department complaining of generalized muscle weakness and palpitations that started earlier today. His vital signs are stable, but his electrocardiogram reveals peaked T waves and widened QRS complexes. Laboratory results show a serum potassium level of $7.6$ mEq/L. Arrange the following pharmacologic interventions in the most appropriate chronological sequence for the acute stabilization and management of this patient.

A 24-year-old woman is brought to the emergency department by paramedics after being found unresponsive in her apartment. Paramedics note an empty bottle of amitriptyline on the nightstand. On arrival, she is obtunded and only withdraws her extremities from painful stimuli. Her Glasgow Coma Scale score is 8. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure 80/50 mmHg, pulse 135/min, and respiratory rate 10/min. A point-of-care electrocardiogram reveals sinus tachycardia with a QRS duration of $160\text{ ms}$ and a prominent terminal R wave in lead aVR.

Arrange the following management steps in the most appropriate chronological sequence for this patient's initial stabilization and subsequent care.

Emergency medical services arrive at the trauma bay with a 38-year-old male construction worker who fell approximately 20 feet (6 meters) from scaffolding, landing on his side. He is groaning and diaphoretic upon arrival.

Upon transfer to the trauma stretcher, his vital signs are:
Temperature: 36.4°C (97.5°F)
Blood pressure: 76/42 mm Hg
Heart rate: 142/min
Respiratory rate: 24/min
Oxygen saturation: 98% on high-flow oxygen

Primary survey confirms a secure airway and equal breath sounds bilaterally. His abdomen is soft and non-distended. Gentle compression of the iliac crests reveals marked mechanical instability of the pelvic ring. Inspection of the perineum demonstrates a rapidly expanding scrotal hematoma and a drop of blood at the urethral meatus.

A Focused Assessment with Sonography for Trauma (FAST) examination shows no pericardial or intra-abdominal free fluid. The trauma team secures bilateral large-bore intravenous access and initiates the massive transfusion protocol with uncrossmatched blood products.

To appropriately manage this patient's life-threatening injuries, which of the following procedural and management steps are INDICATED? (Select all that apply)

A 22-year-old man is brought to the emergency department via ambulance after a high-speed collision in an all-terrain vehicle. He was not wearing a helmet and struck his face heavily on the handlebars. He is combative and making gurgling, high-pitched inspiratory sounds. Vital signs are temperature 37.0°C (98.6°F), blood pressure 105/65 mm Hg, pulse 122/min, and respirations 28/min. Pulse oximetry shows an oxygen saturation of 83% despite receiving high-flow oxygen via a non-rebreather mask. Physical examination reveals severe maxillary and mandibular instability with massive midface edema. There is profuse active bleeding into the oropharynx. The neck is structurally intact without obvious tracheal deviation or hematoma. Attempts at bag-valve-mask ventilation fail to provide adequate chest rise. An experienced emergency physician performs direct laryngoscopy, but the vocal cords cannot be visualized due to heavy bleeding and distorted anatomy. The patient's oxygen saturation drops to 78%. Which of the following is the most appropriate next step in securing this patient's airway?

A patient in the intensive care unit experiences a generalized tonic-clonic seizure. Stat laboratory evaluation reveals a critical serum sodium level of $114 \text{ mEq/L}$. The clinical team must rapidly manage this electrolyte emergency while preventing iatrogenic complications. Arrange the following steps for the treatment, monitoring, and ongoing evaluation of this patient in the most appropriate chronological sequence.

An overweight 55-year-old female visits the ambulatory care clinic for a scheduled blood pressure check. Two weeks ago, she was diagnosed with primary hypertension and prescribed daily oral losartan. Her baseline serum creatinine was $0.9 \text{ mg/dL}$ and serum potassium was $4.2 \text{ mEq/L}$. Today, she feels well and denies any dizziness, headache, or edema. Her blood pressure is $128/78 \text{ mmHg}$. Repeat laboratory testing shows a serum creatinine of $1.1 \text{ mg/dL}$ and a serum potassium of $4.6 \text{ mEq/L}$. Which of the following are the most appropriate next steps in monitoring and treatment evaluation? (Select two)

A 24-year-old woman presents to the clinic after noticing a lump in her right breast 3 weeks ago. She reports no pain, nipple discharge, or systemic symptoms. Her menstrual cycles are regular, and she notes that the lump has not fluctuated in size since she discovered it. She has no personal or family history of breast or ovarian malignancy. On physical examination, a 2.5-cm, firm, mobile, and non-tender mass is palpated in the upper outer quadrant of the right breast. There is no nipple retraction, overlying skin changes, or palpable axillary lymphadenopathy. Which of the following is the most appropriate next step in the diagnostic workup?

A rapid response is called for a hospitalized 32-year-old male with a history of ulcerative colitis who has become acutely hypotensive and lethargic. He has been receiving high-dose intravenous methylprednisolone for the past 72 hours for a severe disease flare. Current vital signs include a temperature of 39.4°C (102.9°F), blood pressure of 82/50 mmHg, and heart rate of 138/min. Physical examination demonstrates marked abdominal distension with diffuse guarding, rigidity, and rebound tenderness. Laboratory studies reveal a leukocyte count of 28,000/mm³. An urgent bedside portable abdominal radiograph shows a transverse colon diameter of 9.5 cm with loss of haustral markings and mucosal edema, without evidence of pneumoperitoneum. The general surgery service is consulted to proceed with emergent operative intervention. Which of the following procedural and perioperative management steps are indicated at this time? (Select all that apply)

A 62-year-old woman with a history of severe osteoarthritis of the right knee and a recent hospitalization for a bleeding peptic ulcer 3 months ago presents to the clinic for worsening knee pain. She requests a prescription for naproxen, stating that her friend uses it and it provides excellent relief. The physician explains that nonsteroidal anti-inflammatory drugs (NSAIDs) are not safe for her due to her recent ulcer. The patient crosses her arms, raises her voice, and says, "But my knee hurts so much, and you're just refusing to help me!"

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

A patient with a known history of primary hyperparathyroidism presents with severe, refractory heartburn and chronic watery diarrhea. Endoscopic evaluation performed recently by an outside gastroenterologist demonstrated severe erosive esophagitis and prominent, multiple ulcerations extending into the second and third portions of the duodenum. The patient is currently taking 80 mg of pantoprazole daily with minimal symptom relief. The clinical team strongly suspects a gastrinoma associated with Multiple Endocrine Neoplasia type 1 (MEN1). Arrange the following diagnostic steps in the most appropriate chronological sequence to biochemically confirm the diagnosis and subsequently localize the tumor.

A multidisciplinary team is coordinating the disposition of an 86-year-old man who is preparing for discharge after a 12-day hospitalization for a large right middle cerebral artery ischemic stroke. He has residual left-sided hemiparesis and oropharyngeal dysphagia, for which a percutaneous endoscopic gastrostomy (PEG) tube was placed. He is now medically stable. The team believes he would benefit from an Inpatient Rehabilitation Facility (IRF). Arrange the following transitional care steps in the most appropriate chronological sequence to ensure a safe transition and adherence to standard discharge protocols.

A 43-year-old female patient presents to the ambulatory clinic for a routine wellness examination. She has a past medical history of severe seropositive rheumatoid arthritis, which has been well-controlled for the past two years on a regimen of methotrexate and adalimumab. She has no other chronic medical conditions. She is a former smoker with a 10 pack-year history, having quit five years ago. Her screening mammogram at age 42 was normal, and a Pap smear with high-risk human papillomavirus (HPV) testing performed one year ago was negative. Her immunization records indicate she received a tetanus, diphtheria, and acellular pertussis (Tdap) booster three years ago, an intramuscular inactivated influenza vaccine two weeks ago, and a 20-valent pneumococcal conjugate vaccine (PCV20) one year ago. Her vital signs are normal, and physical examination shows no active joint inflammation. Which of the following is the most appropriate next step in preventive care for this patient?

A 42-year-old woman is evaluated in the hospital for fever, chills, and severe right-sided flank pain that began $12$ hours ago. She underwent a difficult laparoscopic total hysterectomy and bilateral salpingo-oophorectomy for severe endometriosis $4$ days ago. Her temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $105/65$ mm Hg, pulse is $112$/min, and respirations are $20$/min. Physical examination reveals marked right costovertebral angle tenderness. Her abdomen is soft with well-healing laparoscopic incisions and mild bilateral lower quadrant tenderness. Laboratory studies show a leukocyte count of $18,500/\mu\text{L}$ and a serum creatinine level of $2.3$ mg/dL (baseline was $0.8$ mg/dL preoperatively). A bedside renal ultrasound demonstrates severe right-sided hydronephrosis with no left-sided abnormalities. Which of the following is the most appropriate next step in management?

An outpatient consultation is arranged for a $57$-year-old male due to a five-week history of significant weight loss, constant resting tremor, and profound heat intolerance. He has a known history of severe ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$, as well as recurrent sustained ventricular tachycardia for which an implantable cardioverter-defibrillator was placed two years ago. His medication regimen includes lisinopril, metoprolol succinate, spironolactone, and amiodarone. He has been taking amiodarone consistently for the past $20$ months.

Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $132/78 \text{ mmHg}$, and an irregular heart rate of $112/\text{min}$. Physical examination reveals a fine tremor of the outstretched hands and a hyperdynamic precordium. The thyroid gland is normal in size, non-tender, and without palpable nodules.

Laboratory studies reveal:
Thyroid-stimulating hormone (TSH): $<0.01 \mu\text{U/mL}$
Free thyroxine (T4): $4.6 \text{ ng/dL}$ (Reference: $0.8-1.8 \text{ ng/dL}$)
Total triiodothyronine (T3): $210 \text{ ng/dL}$ (Reference: $80-200 \text{ ng/dL}$)

A color flow Doppler ultrasonography of the anterior neck demonstrates a structurally normal thyroid gland with markedly reduced vascularity.

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

Match each patient scenario involving a refusal of medical intervention with the most appropriate assessment of decision-making capacity and subsequent clinical action.

Emergency responders arrive at the trauma bay with a 45-year-old man who was just rescued from a residential house fire. He had been trapped in a smoke-filled, enclosed room for approximately 15 minutes before extraction. Upon arrival, the patient is awake but visibly anxious and restless. He complains of a severe sore throat and speaks with a noticeably hoarse voice. Physical examination reveals singed bilateral nasal hairs, carbonaceous sputum in the oropharynx, and superficial partial-thickness burns distributed over his face, anterior neck, and upper chest. Current vital signs include a temperature of 37.2°C (99.0°F), blood pressure of 138/86 mm Hg, heart rate of 112/min, and a respiratory rate of 26/min. His oxygen saturation is 98% while receiving supplemental oxygen at 15 L/min via a non-rebreather mask. Auscultation of the lungs reveals clear bilateral breath sounds, but harsh, high-pitched inspiratory sounds are prominently heard over the anterior neck. Which of the following is the most appropriate next step in the management of this patient?