All practice questions

A 28-year-old woman is brought to the emergency department by her husband due to severe agitation, confusion, and high fever. She has a history of Graves disease but stopped taking her medications three months ago. On examination, her temperature is $40.2^\circ\text{C}$ ($104.4^\circ\text{F}$), blood pressure is $170/95\text{ mmHg}$, heart rate is $155/\text{min}$ and irregular, and respiratory rate is $24/\text{min}$. Physical examination reveals diaphoresis, a prominent goiter, lid lag, and a fine bilateral hand tremor. An electrocardiogram shows atrial fibrillation with a rapid ventricular response. A clinical diagnosis of thyroid storm is made, and aggressive pharmacologic intervention is required.

Arrange the following pharmacologic interventions in the most appropriate chronological sequence for this patient's acute and long-term management:

A 46-year-old man comes to the primary care clinic for a routine wellness examination and to establish care. He reports feeling well and has no concerns. His medical history is unremarkable, and he takes no daily medications. He has never smoked cigarettes, consumes one or two alcoholic beverages per week, and does not use illicit drugs. Family history is negative for malignancies and cardiovascular disease. Vital signs are within normal limits, and a complete physical examination is unremarkable. A review of his medical records reveals that he has not undergone any preventive health screenings or diagnostic tests in the past decade. Which of the following is the most appropriate preventive care recommendation for this patient at this time?

Emergency medical personnel transport a $56$-year-old man to the resuscitation bay following a massive episode of hematemesis at his residence. On arrival, he is profoundly lethargic and grimaces only to sternal rub. Active vomiting of dark red blood continues. Vital signs include a temperature of $36.2^\circ \mathrm{C}$ ($97.2^\circ \mathrm{F}$), a blood pressure of $70/40$ mmHg, a heart rate of $142$/min, and a respiratory rate of $26$/min. Pulse oximetry cannot be obtained due to severe peripheral vasoconstriction. Arrange the following interventions in the most appropriate sequential order for the stabilization of this patient.

A 62-year-old man presents to the clinic with a two-day history of burning with urination and increased urinary frequency. He reports no fever, chills, flank pain, or gross hematuria. His medical history is significant for a deep vein thrombosis six months ago, for which he takes warfarin. His international normalized ratio (INR) checked one week ago was $2.5$. Vital signs are within normal limits. Urinalysis is positive for nitrites and leukocyte esterase. The patient has no known drug allergies and his renal function is normal. To effectively treat his infection while minimizing the risk of a severe drug-drug interaction that could elevate his INR, which of the following is the most appropriate empiric pharmacologic intervention?

A $64$-year-old man is preparing for discharge from the cardiac care unit following an anterior ST-segment elevation myocardial infarction (STEMI). On the day of admission, he underwent successful primary percutaneous coronary intervention with the placement of a drug-eluting stent in the left anterior descending artery. His past medical history is significant for type $2$ diabetes mellitus, moderate persistent asthma, and osteoarthritis of the knees.

Echocardiography performed prior to discharge demonstrates a left ventricular ejection fraction of $35\%$. He is currently euvolemic, hemodynamically stable, and completely asymptomatic. Renal function is normal with a serum creatinine of $1.1$ mg/dL, and potassium is $4.3$ mEq/L.

He is currently taking aspirin and high-intensity atorvastatin, which will be continued. To optimize this patient's long-term morbidity and mortality, which of the following medications should also be included in his discharge regimen? (Select all that apply)

A 68-year-old woman with a history of type 2 diabetes mellitus is brought to the emergency department due to altered mental status, fever, and right-sided flank pain for the past 24 hours. Vital signs reveal a temperature of 39.2°C (102.6°F), blood pressure of 85/50 mm Hg, heart rate of 122/min, and respiratory rate of 24/min. Laboratory studies show a leukocyte count of 22,000/mm³. Non-contrast CT of the abdomen and pelvis demonstrates an 8-mm calculus in the right proximal ureter with moderate hydroureteronephrosis and perinephric stranding. Arrange the following interventions in the most appropriate sequence for the management of this patient.

A 68-year-old man is evaluated in the intensive care unit for persistent hypotension. He was admitted 12 hours ago for severe community-acquired pneumonia and was empirically started on intravenous ceftriaxone and azithromycin. His medical history includes hypertension, type 2 diabetes mellitus, and stage 3a chronic kidney disease. Since admission, he has received a total of 4 liters of intravenous lactated Ringer solution. His current vital signs are temperature 38.6°C (101.5°F), blood pressure 80/52 mmHg (mean arterial pressure 61 mmHg), heart rate 118/min, and respiratory rate 22/min. Oxygen saturation is 94% on a high-flow nasal cannula. Bedside echocardiography demonstrates hyperdynamic left ventricular function and a distended inferior vena cava with minimal respiratory variation. Urine output over the past 4 hours has been 15 mL/hr. Which of the following is the most appropriate next pharmacologic intervention?

A $32$-year-old woman is admitted to the hospital with a newly diagnosed acute pulmonary embolism. She is hemodynamically stable and has no significant past medical history. Her only home medication is an oral contraceptive pill. Her body mass index is $24$ kg/m $^2$, and her serum creatinine is $0.7$ mg/dL. The medical team initiates therapeutic-dose subcutaneous enoxaparin. They plan to transition her to an oral anticoagulant prior to discharge. During the initial period while she is receiving solely enoxaparin, which of the following is the most appropriate strategy for monitoring the anticoagulant effect of this medication?

A 55-year-old woman is preparing for discharge following an admission for a non-ST-segment elevation myocardial infarction (NSTEMI). She underwent a successful percutaneous coronary intervention with the placement of a drug-eluting stent. Her past medical history includes hypertension and hyperlipidemia. Her vitals are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $122/78\text{ mmHg}$, pulse $68/\text{min}$, and respiratory rate $14/\text{min}$. An echocardiogram demonstrates a left ventricular ejection fraction of $55\%$. In addition to dual antiplatelet therapy with aspirin and clopidogrel, which of the following pharmacologic interventions should be included in her discharge regimen to provide a long-term mortality benefit? (Select all that apply)

A 75-year-old man is hospitalized for his fourth exacerbation of heart failure in the past 6 months. He has New York Heart Association (NYHA) Class IV heart failure with a left ventricular ejection fraction of 15%. His home medications include maximum tolerated doses of carvedilol, sacubitril-valsartan, spironolactone, and dapagliflozin. During this admission, he required a continuous milrinone infusion to relieve severe dyspnea at rest and maintain adequate end-organ perfusion. Over the past 48 hours, attempts to wean the milrinone have repeatedly resulted in worsening respiratory distress and an acute rise in his serum creatinine from 1.4 mg/dL to 2.9 mg/dL. He has been evaluated by the advanced heart failure team and is not a candidate for a ventricular assist device or cardiac transplantation due to age and multiple comorbidities.

During a family meeting, the patient states, "I am tired of being in the hospital. I just want to go home and be comfortable. I do not want any more aggressive treatments or to be readmitted." He lives in a single-story home with his daughter, who is willing and able to provide 24-hour care.

Which of the following is the most appropriate disposition for this patient?

Pair each of the following ambulatory patient scenarios with the single most appropriate, evidence-based preventive screening or immunization.

Match each clinical presentation of a patient with severe or resistant hypertension to the most appropriate next diagnostic test in their workup sequence.

A 28-year-old man is brought to the emergency department by paramedics following an altercation during which he sustained multiple stab wounds to the left hemithorax and mid-abdomen. On arrival, he is extremely agitated, diaphoretic, and confused. Vital signs show a temperature of $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), blood pressure of $68/40\text{ mm Hg}$, pulse of $145\text{/min}$, and respiratory rate of $38\text{/min}$. Oxygen saturation is $84\%$ on high-flow oxygen via a nonrebreather mask. Physical examination reveals markedly distended neck veins, tracheal deviation to the right, and absent breath sounds over the left lung fields. The abdomen is rigid with severe diffuse tenderness to palpation. Capillary refill is delayed.

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

A 61-year-old man presents to the ambulatory clinic to establish care. He has not seen a physician in over 15 years. He feels well and has no acute complaints. His only past medical history is hyperlipidemia, for which he previously took a medication but stopped 10 years ago. He currently takes no medications. He smoked one pack of cigarettes daily from age 20 to 50 but quit 11 years ago (30 pack-year history). He drinks 1 to 2 beers on weekends. Family history is notable for a father who died of a myocardial infarction at age 78. Vital signs include blood pressure 138/86 mmHg, heart rate 72/min, respiratory rate 14/min, and BMI 27 kg/m². Physical examination is unremarkable. Which of the following preventive screening interventions are indicated for this patient at this visit according to current guidelines? (Select all that apply)

A 42-year-old man presents to the emergency department after a single episode of vomiting dark, coffee-ground-like material earlier this morning. He also reports mild, burning epigastric pain that started a week ago. He denies melena, hematochezia, lightheadedness, or syncope. He has no prior medical conditions and occasionally takes over-the-counter ibuprofen for back pain. He lives with his wife, who drove him to the hospital, and they reside 10 minutes away.

On physical examination, his temperature is 37.0°C (98.6°F), blood pressure is 128/82 mm Hg, pulse is 78/min, and respiratory rate is 14/min. Orthostatic vital signs show no significant changes. The abdomen is soft with mild epigastric tenderness to deep palpation, but there is no guarding or rebound. Digital rectal examination reveals brown stool that is guaiac positive.

Laboratory results are as follows:

Hemoglobin: 14.8 g/dL
Platelet count: 240,000/mm³
Blood urea nitrogen: 14 mg/dL
Serum creatinine: 0.8 mg/dL
Liver function tests: Normal
Prothrombin time: 11 sec (INR 1.0)

The patient is observed in the emergency department for 4 hours. He has no further episodes of emesis, his vital signs remain stable, and he tolerates oral liquids without difficulty.

Which of the following is the most appropriate disposition for this patient?

A 34-year-old man is brought to the emergency department by paramedics after falling approximately 30 feet (9 meters) from a scaffolding at a construction site. On arrival, he is moaning incomprehensibly, does not open his eyes to painful stimuli, and exhibits abnormal flexion posturing. He has pooled blood and secretions in his oropharynx. His respiratory rate is 8/min and shallow. Blood pressure is 78/40 mmHg, and heart rate is 142/min. Oxygen saturation is 84% on room air. Physical examination reveals a large scalp hematoma and an obviously deformed, swollen right thigh. Which of the following interventions should be ordered simultaneously as the most appropriate immediate next steps in management? (Select two)

A $29$-year-old woman is evaluated in the clinic for a follow-up visit. Six weeks ago, she was diagnosed with Graves disease after presenting with a $3$-month history of weight loss, heat intolerance, and palpitations. At that time, laboratory studies showed a markedly suppressed thyroid-stimulating hormone (TSH) level and elevated free thyroxine (T4) and total triiodothyronine (T3) levels. She was started on methimazole $20$ mg daily.

Today, she reports feeling much better. She has regained $2$ kg ($4.4$ lbs) and her palpitations and heat intolerance have resolved. Her heart rate is $72$/min and blood pressure is $112/70$ mm Hg. Physical examination shows a small, non-tender, symmetric goiter. There is no tremor or exophthalmos.

Repeat laboratory studies show:
Thyroid-stimulating hormone (TSH): $<0.01$ $\mu$ U/mL (reference: $0.4-4.2$ $\mu$ U/mL)
Free thyroxine (T4): $1.2$ ng/dL (reference: $0.8-1.8$ ng/dL)
Total triiodothyronine (T3): $130$ ng/dL (reference: $80-200$ ng/dL)

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

A 71-year-old man is hospitalized for the third time in two months due to complications of end-stage liver disease, including refractory ascites and recurrent hepatic encephalopathy. Upon admission two days ago, he was confused and asterixis was present. Following aggressive treatment with lactulose and rifaximin, his mental status has returned to baseline. During morning rounds, the patient calmly states that he is exhausted by the frequent hospitalizations and poor quality of life. He expresses a desire to stop all liver-directed therapies, avoid any future intensive care admissions, and focus exclusively on comfort.

His daughter, who is his legally appointed healthcare proxy, is at the bedside and becomes very upset. She tells the physician, "You cannot listen to him! He was completely delirious yesterday, which proves he is legally incompetent to make this choice. As his proxy, I demand that you continue full medical treatment."

The physician evaluates the patient and finds him to be fully oriented to person, place, time, and situation. The patient accurately describes his medical condition, understands that refusing further treatment will lead to his death, and clearly explains that he values comfort over prolonged suffering.

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

A 52-year-old man is admitted to the intensive care unit with septic shock secondary to a perforated viscus. The critical care team determines that a central venous catheter is required for the administration of vasopressors and hemodynamic monitoring. The physician prepares to insert a catheter into the right internal jugular vein. Which of the following interventions is the most effective evidence-based measure to prevent a central line-associated bloodstream infection (CLABSI) during this procedure?

A 62-year-old man comes to the clinic to discuss the results of a recent ambulatory electrocardiogram, which confirmed newly diagnosed atrial fibrillation. His past medical history is significant for major depressive disorder treated with fluoxetine, and severe persistent asthma treated with an inhaled corticosteroid and formoterol. The physician recommends starting an oral anticoagulant to reduce the risk of stroke. The patient becomes visibly anxious and states, "I read online that those blood thinners can make you bleed to death. I do not want to take them. Instead, I want to manage this naturally and start taking an over-the-counter St. John's wort supplement, which my friend said is great for your heart and mood." Which of the following is the most appropriate next step in counseling this patient?