All practice questions

A 71-year-old woman with widely metastatic breast cancer is admitted to the inpatient hospice unit for end-of-life care. She is actively dying and minimally responsive. Over the past 24 hours, she has experienced episodes of severe terminal delirium with agitation, which are currently being managed with scheduled haloperidol. Her family is now highly distressed by loud, gurgling respiratory sounds originating from her upper airway. Auscultation reveals coarse upper airway transmitted sounds with clear lung bases. Her respiratory rate is 14/min, and she shows no signs of air hunger, accessory muscle use, or labored breathing during quiet intervals. Which of the following is the most appropriate next step in the management of this patient's respiratory symptom?

A large regional medical center is preparing to transition its intensive care units to a new continuous renal replacement therapy (CRRT) machine model. The nursing and nephrology directors are concerned about potential adverse events during the transition period. They convene a multidisciplinary group to map out the new CRRT setup process, determine what could potentially go wrong at each step, estimate the likelihood of these failures occurring, and calculate a hazard score to prioritize preventive interventions before the machines are deployed. Which of the following quality improvement frameworks is this hospital utilizing?

A $45$-year-old man comes to the emergency department due to a $2$-day history of worsening left leg swelling and pain. He was diagnosed with active pulmonary tuberculosis three weeks ago and is currently in the intensive phase of treatment with rifampin, isoniazid, pyrazinamide, and ethambutol. He also has a history of HIV, for which he takes dolutegravir $50\text{ mg}$ twice daily, tenofovir alafenamide, and emtricitabine. His viral load is undetectable, and his CD4 count is $450/\text{mm}^3$. Vital signs are within normal limits. Physical examination reveals unilateral edema, erythema, and tenderness of the left calf. Laboratory studies show a serum creatinine of $0.9\text{ mg/dL}$ and normal liver function tests. A duplex ultrasound of the left lower extremity demonstrates a noncompressible, acute thrombus in the left popliteal and femoral veins. Which of the following is the most appropriate pharmacologic intervention for managing this patient's deep vein thrombosis?

Evaluate the following patient encounters. Match each clinical vignette to the single most appropriate next best step in preventive care and screening.

A 73-year-old woman with advanced Alzheimer dementia is admitted to the surgical ward with a necrotizing infection of her right foot. She is persistently disoriented to time and place, cannot comprehend her diagnosis, and lacks the clinical capacity to make medical decisions. The surgical team strongly recommends a below-the-knee amputation to prevent the localized infection from progressing to life-threatening systemic sepsis. She is widowed, her only child is deceased, and her parents are deceased. The patient is accompanied by her former business partner and her younger sister. No written advance directive or Healthcare Proxy was ever established. The business partner presents a notarized Durable Power of Attorney for Financial Affairs and insists on consenting to the surgery, stating, "I hold her power of attorney, and she must have this operation to live." The sister opposes the surgery, stating that the patient had previously witnessed a friend undergo an amputation and explicitly told her, "I would rather die whole than live without a limb." Which of the following is the most appropriate next step in obtaining medical consent for this patient?

Review the following patient clinical profiles and match each with the single most appropriate next step in preventive care or screening based on current evidence-based guidelines.

A $64$-year-old man is brought to the emergency department via ambulance due to the sudden onset of excruciating, "tearing" chest pain that radiates to his interscapular region. The pain began $1$ hour ago while he was watching television. He has a history of poorly controlled hypertension, type 2 diabetes mellitus, and a $40$-pack-year smoking history. On arrival, he appears pale, diaphoretic, and lethargic. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $80/50\text{ mm Hg}$ in the right arm and $115/65\text{ mm Hg}$ in the left arm, heart rate is $124/\text{min}$, and respiratory rate is $24/\text{min}$. Cardiopulmonary examination reveals a faint diastolic decrescendo murmur at the right upper sternal border. An electrocardiogram demonstrates sinus tachycardia with voltage criteria for left ventricular hypertrophy but no acute ischemic changes. Portable chest radiography shows a widened mediastinum. Initial laboratory studies reveal a serum creatinine concentration of $2.9\text{ mg/dL}$. Which of the following is the most appropriate next step in diagnostic imaging?

An emergency department physician is assessing a 22-year-old nulliparous woman who complains of a persistent, throbbing headache for the past two weeks, accompanied by a 'whooshing' sound in her ears. Her body mass index is $21 \text{ kg/m}^2$. Visual acuity is intact, but fundoscopy reveals bilateral papilledema. An MRI of the brain and magnetic resonance venography show no abnormalities. A lumbar puncture demonstrates an opening pressure of $320 \text{ mm H}_2\text{O}$ with normal cerebrospinal fluid parameters. When taking a detailed medical history, the physician discovers the patient recently began an aggressive over-the-counter regimen for skin breakouts. Which of the following specific historical elements is most likely responsible for this patient's presentation?

A 58-year-old man presents to the outpatient clinic for evaluation of a wound on his right foot that he first noticed two weeks ago. He has a 15-year history of type 2 diabetes mellitus complicated by peripheral neuropathy and stage 4 chronic kidney disease. The patient does not report any fever, chills, or systemic symptoms. Vital signs are within normal limits.

Physical examination of the right foot reveals a $2 \text{ cm} \times 2 \text{ cm}$ ulcer on the plantar surface of the first metatarsophalangeal joint. The ulcer base is covered with fibrinous exudate, and there is $3 \text{ cm}$ of surrounding erythema, warmth, and induration. During wound exploration, a sterile metal probe is easily advanced through the ulcer base and palpates hard, gritty tissue. Dorsalis pedis and posterior tibial pulses are diminished but detectable via handheld Doppler.

Laboratory studies are as follows:

Which of the following is the most appropriate initial imaging study to order for this patient?

A 42-year-old man comes to the clinic for follow-up of difficult-to-control hypertension. He has a 5-year history of elevated blood pressure that remains poorly controlled despite adherence to maximal tolerated doses of amlodipine, lisinopril, and chlorthalidone. Today, his blood pressure is 168/100 mmHg. Routine laboratory testing reveals a serum potassium concentration of 3.0 mEq/L and a serum sodium concentration of 144 mEq/L. He takes no other medications or over-the-counter supplements. The physician suspects a specific endocrine etiology for his secondary hypertension.

Arrange the following diagnostic steps for the suspected condition in the most appropriate sequential order, from initial screening to preoperative evaluation.

A 55-year-old man with a history of alcohol-associated cirrhosis is rushed to the triage bay by paramedics following multiple episodes of massive hematemesis at his residence. On physical examination, the patient is obtunded, pooling blood in the oropharynx, and withdraws only to painful stimuli. Vital signs show a heart rate of 134/min, blood pressure of 72/38 mm Hg, respiratory rate of 28/min, and oxygen saturation of 89% on room air. Arrange the following acute management steps in the most appropriate chronological order for this patient's initial stabilization.

A 28-year-old construction worker is transported to the trauma bay via helicopter after being crushed beneath a collapsed concrete retaining wall. On arrival, he is moaning and visibly pale but follows simple commands. His airway is patent, and breath sounds are equal bilaterally. Vital signs show a temperature of 36.2°C (97.2°F), blood pressure of 72/40 mmHg, pulse of 138/min, and respiratory rate of 26/min. Oxygen saturation is 95% on high-flow oxygen. Primary survey reveals massive ecchymoses over the lower abdomen, flanks, and perineum. On gentle palpation, the pubic symphysis feels widely diastatic. There is a small amount of blood visible at the urethral meatus. No obvious external hemorrhage is noted on the extremities or torso. Which of the following interventions should be ordered simultaneously as the initial management for this patient? (Select 2)

A 61-year-old woman is admitted to the hospital with a 4-day history of high-grade fevers, a nonproductive cough, and right-sided pleuritic chest pain. She underwent an orthotopic liver transplant 7 months ago for primary biliary cholangitis. Her home medications include tacrolimus, mycophenolate mofetil, and low-dose prednisone. Vital signs show a temperature of 38.8°C (101.8°F), blood pressure of 118/74 mm Hg, pulse of 102/min, and respiratory rate of 20/min. Pulse oximetry is 96% on room air. Laboratory studies reveal a serum creatinine of 1.1 mg/dL and normal liver function tests. A non-contrast computed tomography scan of the chest demonstrates a 3-cm nodular opacity in the right upper lobe surrounded by a halo of ground-glass attenuation. Serum galactomannan assay is strongly positive. The medical team plans to initiate intravenous voriconazole therapy. Which of the following is the most appropriate management step regarding this patient's pharmacologic regimen?

A 45-year-old woman is brought to the emergency department due to altered mental status, high fever, and severe agitation. Her husband reports she has a history of Graves disease but stopped taking her medications three months ago. On physical examination, her temperature is 39.8°C (103.6°F), blood pressure is 160/70 mmHg, and heart rate is 145/min and irregular. She is visibly tremulous, diaphoretic, and delirious. An electrocardiogram confirms atrial fibrillation with a rapid ventricular response. A diagnosis of thyroid storm is suspected.

Which of the following pharmacologic interventions are appropriate components of the immediate management of this patient? (Select all that apply)

A 55-year-old woman presents to the clinic complaining of generalized weakness, muscle aches, and difficulty climbing stairs that has progressively worsened over the past three months. She also notes increasing fatigue, a 4-kg (8.8-lb) weight gain, and persistent constipation during this time. Two weeks ago, she was diagnosed with a mild upper respiratory infection and completed a 5-day course of azithromycin. Her chronic medical conditions include hypertension and hyperlipidemia, for which she takes amlodipine and rosuvastatin. She has been on both of these daily medications for four years without any recent dose adjustments. Vital signs show a blood pressure of 132/84 mm Hg, heart rate of 56/min, respiratory rate of 14/min, and temperature of 36.4°C (97.5°F). Physical examination reveals 4/5 muscle strength in the bilateral deltoids and hip flexors. Deep tendon reflexes are 1+ at the patella and Achilles, demonstrating a noticeably delayed relaxation phase. The remainder of the physical examination is unremarkable. Laboratory studies reveal a serum creatine kinase (CK) level of 1,850 U/L and a normal serum creatinine. Which of the following is the most likely underlying cause of this patient's findings?

A 64-year-old man is brought to the emergency department by paramedics after his wife found him lethargic and confused at home. She reports that he had been complaining of progressive, severe upper abdominal pain and nausea over the past three days. His past medical history is significant for osteoarthritis, for which he takes high-dose ibuprofen daily, and hypertension. On physical examination, the patient is obtunded and profusely diaphoretic. Temperature is 39.4°C (102.9°F), blood pressure is 72/40 mmHg, pulse is 132/min, and respirations are 28/min. Pulse oximetry is 93% on room air. Cardiopulmonary examination reveals tachycardia with distant heart sounds and rapid, shallow breathing. Abdominal examination demonstrates a rigid, board-like abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Which of the following is the most appropriate initial step in the management of this patient?

Emergency medical responders transport a $71$-year-old female to the acute care bay due to the abrupt onset of crushing substernal chest pain and profound respiratory distress. Her husband reports that she experienced a myocardial infarction $3$ days ago but eloped from the hospital against medical advice. On examination, the patient is somnolent, cyanotic, and exhibits severe suprasternal retractions. Copious pink, frothy secretions are pooling in her oropharynx. Auscultation reveals a harsh, blowing holosystolic murmur at the cardiac apex and diffuse coarse crackles throughout both lung fields. Vital signs include a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate of $132\text{/min}$, blood pressure of $72/42\text{ mm Hg}$, and respiratory rate of $36\text{/min}$. Pulse oximetry shows an oxygen saturation of $81\%$ on room air. Which of the following represents the most critical immediate intervention for this patient?

A $68$-year-old woman is hospitalized for an acute exacerbation of chronic obstructive pulmonary disease (COPD). Her baseline $\text{FEV}_1$ is $35\%$ of predicted. Over the past $48$ hours, she has been receiving intravenous methylprednisolone, nebulized ipratropium-albuterol, and non-invasive positive pressure ventilation. On hospital day $3$, her respiratory status has improved, and she is transitioned to nasal cannula oxygen. However, she begins to complain of new-onset palpitations. Vital signs show a blood pressure of $122/78 \text{ mmHg}$ and a heart rate of $128/\text{min}$. A $12$-lead electrocardiogram demonstrates an irregular rhythm with three distinct P-wave morphologies in the same lead and an irregular PR interval. Laboratory studies show a serum potassium of $4.2 \text{ mEq/L}$ and a serum magnesium of $2.1 \text{ mg/dL}$. Which of the following is the most appropriate pharmacologic intervention to manage this patient's arrhythmia?

A 19-year-old man presents to the emergency department with severe, sudden-onset right scrotal pain that awoke him from sleep two hours ago. He reports no recent trauma, fever, dysuria, or urethral discharge. Vital signs are within normal limits except for a heart rate of 105/min. On physical examination, the right testicle is diffusely swollen, exquisitely tender, and has a transverse lie. It is positioned significantly higher in the scrotum compared to the left testicle. When the examiner manually elevates the right hemiscrotum, the patient reports no relief in his pain. Based on the most likely diagnosis, which of the following additional physical examination findings is most likely to be present in this patient?

A 48-year-old female presents to the clinic with a 6-month history of diffuse, dull bone pain and worsening muscle weakness. She reports increasing difficulty rising from a seated position and climbing the stairs at her home. Her past medical history is notable for a Roux-en-Y gastric bypass performed two years ago for severe obesity. She acknowledges skipping her recommended daily nutritional supplements for the past year. Her vital signs are within normal limits. Physical examination reveals generalized tenderness upon palpation of the sternum and anterior tibias. Neurological examination demonstrates $4/5$ strength in the bilateral hip flexors and quadriceps, with normal deep tendon reflexes. A routine chemistry panel shows a serum calcium of $8.2 \text{ mg/dL}$ (reference: $8.5-10.5 \text{ mg/dL}$) and phosphorus of $2.6 \text{ mg/dL}$ (reference: $2.8-4.5 \text{ mg/dL}$). Which of the following is the most appropriate next diagnostic step?