All practice questions

A 71-year-old man is admitted to the intensive care unit with a 3-day history of worsening confusion, severe weakness, and diffuse abdominal pain with constipation. He has a history of squamous cell carcinoma of the lung with diffuse metastases to the ribs and thoracic spine. The patient has been unable to drink fluids for the past 2 days due to profound nausea. Vital signs show temperature $37.2^\circ\text{C}$, heart rate $118\text{/min}$, blood pressure $92/58\text{ mmHg}$, and respiratory rate $18\text{/min}$. Physical examination reveals a somnolent patient who withdraws from painful stimuli. His mucous membranes are extremely dry, and skin turgor is significantly decreased.

Initial laboratory studies reveal:
Serum sodium: $148\text{ mEq/L}$
Serum potassium: $4.2\text{ mEq/L}$
Serum chloride: $106\text{ mEq/L}$
Serum bicarbonate: $24\text{ mEq/L}$
Blood urea nitrogen: $82\text{ mg/dL}$
Serum creatinine: $4.8\text{ mg/dL}$ (baseline $1.2\text{ mg/dL}$)
Serum total calcium: $16.2\text{ mg/dL}$
Serum albumin: $3.0\text{ mg/dL}$
Serum phosphorus: $2.1\text{ mg/dL}$

Aggressive intravenous hydration with $0.9\%$ normal saline and administration of subcutaneous calcitonin are immediately initiated. Which of the following is the most appropriate additional pharmacologic intervention to provide sustained control of this patient's hypercalcemia?

During a routine follow-up appointment, a $34$-year-old female is evaluated for persistently elevated blood pressure. She was diagnosed with hypertension six months ago and is currently adherent to a regimen of maximum-dose amlodipine, chlorthalidone, and lisinopril. Despite this therapy, her home blood pressure readings consistently range from $160/100$ to $175/110 \text{ mm Hg}$. The patient mentions occasional mild headaches but otherwise feels well. She does not smoke or consume alcohol. Family history is notable for hypertension in her father, diagnosed at age $55$.

Vital signs in the office today show a blood pressure of $168/104 \text{ mm Hg}$ and a heart rate of $76/\text{min}$. Physical examination reveals a thin adult with a body mass index of $22 \text{ kg/m}^2$. Cardiopulmonary examination is unremarkable. Auscultation of the abdomen reveals a soft, high-pitched systolic bruit over the right upper quadrant.

Laboratory studies are obtained and compared to baseline values from three weeks ago, just prior to the addition of lisinopril to her regimen:

Which of the following is the most appropriate next step in the diagnostic workup?

A $27$-year-old man presents to the emergency department with a $5$-day history of abdominal pain. The pain initially began around his umbilicus and was associated with nausea and two episodes of nonbloody emesis. Three days ago, the pain migrated to the right lower quadrant and became more constant. Yesterday, he felt slightly better, but today he developed a fever and worsening, severe right lower quadrant pain. Temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $122/78\text{ mmHg}$, pulse is $112/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals a palpable, tender, $6\text{ cm}$ mass in the right lower quadrant. Bowel sounds are hypoactive. Laboratory studies show a leukocyte count of $17,200/\text{mm}^3$ with a neutrophil predominance. Computed tomography of the abdomen and pelvis with intravenous contrast reveals a ruptured appendix with an adjacent $5.2\text{ cm}$ rim-enhancing periappendiceal fluid collection. Which of the following is the most appropriate next step in management?

A 58-year-old man with a history of stage 4 chronic kidney disease and heart failure is brought to the emergency department due to profound generalized muscle weakness and palpitations that began earlier today. His medications include lisinopril and newly prescribed spironolactone. His heart rate is 54/min, and blood pressure is 112/68 mmHg. An electrocardiogram reveals widened QRS complexes merging with tall, peaked T waves in a "sine wave" pattern. A point-of-care basic metabolic panel shows a serum potassium level of 8.4 mEq/L.

Arrange the following pharmacologic interventions in the most appropriate chronological sequence for the acute management of this patient's condition.

A $58$-year-old man is brought to the emergency department by his husband due to severe, worsening mid-back pain over the past week. The patient has a history of type 2 diabetes mellitus and intravenous substance use. Over the last $12$ hours, he has developed profound weakness in both legs and has been unable to urinate. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, pulse is $108/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals marked tenderness to percussion over the midthoracic spine. Neurological examination shows $3/5$ muscle strength in the bilateral lower extremities, decreased sensation to pinprick below the umbilicus, and hyperreflexia at the patellae with bilateral upgoing plantar reflexes. Digital rectal examination demonstrates decreased anal sphincter tone. Which of the following are the most appropriate immediate steps in this patient's diagnostic workup? (Select all that apply)

Paramedics transport an elderly female resident of an assisted living facility to the acute care unit. Staff at the facility reported she had been complaining of unremitting abdominal discomfort and had vomited several times over the prior half-day. She is $72$ years old. Her documented medical history is significant for chronic hypertension, paroxysmal atrial fibrillation, and a history of an open cholecystectomy a decade ago. Vital signs upon triage show a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), a blood pressure of $85/50\text{ mm Hg}$, a heart rate of $128/\text{min}$, and a respiratory rate of $24/\text{min}$. Her abdomen is markedly distended. Palpation elicits diffuse guarding and rebound tenderness across all quadrants. Auscultation reveals a silent abdomen. Close inspection of the right lower quadrant demonstrates a prominent, non-reducible mass adjacent to her prior surgical scar. The skin overlying the mass is notably erythematous, warm to the touch, and exquisitely painful upon minimal contact. Which of the following interventions are indicated for this patient? (Select all that apply)

A 26-year-old man with a known history of ulcerative colitis is admitted to the hospital with an acute flare. He reports 10 to 12 bloody bowel movements daily and severe lower abdominal pain. His temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $110/70 \text{ mm Hg}$, and heart rate is $118/min$. Laboratory results show a hemoglobin of $9.8 \text{ g/dL}$, leukocyte count of $14,000/\mu\text{L}$, and C-reactive protein (CRP) of $90 \text{ mg/L}$. A diagnosis of acute severe ulcerative colitis (ASUC) is made.

Arrange the following steps in the standard evidence-based chronological sequence for the therapeutic management and monitoring of this patient.

A $42$-year-old man is brought to the emergency department after a high-speed motorcycle crash. He is agitated, pale, and diaphoretic. His temperature is $36.2^\circ C$, heart rate is $142/min$, blood pressure is $76/40$ mmHg, and respiratory rate is $28/min$. The airway is patent, and breath sounds are present and equal bilaterally. A cervical spine collar is in place. The abdomen is grossly distended and rigid, with diffuse tenderness to palpation. The pelvis is mechanically stable to anterior-posterior and lateral compression. Bedside focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the hepatorenal and splenorenal recesses. Two large-bore intravenous lines are placed, and balanced crystalloid resuscitation is initiated alongside an uncrossmatched blood transfusion. Which of the following is the most appropriate next step in the management of this patient?

A multidisciplinary rounding team is determining the optimal discharge pathway for a 78-year-old man who has been hospitalized for six days due to methicillin-resistant *Staphylococcus aureus* bacteremia secondary to a cellulitis infection. He has been afebrile for 48 hours, and repeat blood cultures show no growth. Vital signs are normal, except for a heart rate of 92/min. Laboratory studies show a white blood cell count of $11,200/\mathrm{mm}^3$ (down from $18,500/\mathrm{mm}^3$ on admission) and a serum creatinine of $1.3\text{ mg/dL}$ (baseline $1.2\text{ mg/dL}$). The infectious disease service recommends an additional four weeks of intravenous vancomycin. Prior to admission, the patient lived alone and was completely independent. Currently, due to profound deconditioning, he requires moderate assistance with bed-to-chair transfers and ambulates less than 10 feet with a walker. Therapy evaluations note that he fatigues rapidly, tolerating a maximum of 45 minutes of active physical and occupational therapy per day. His nearest relative lives in another state. Which of the following is the most appropriate care setting transition for this patient?

A 29-year-old woman is brought to the emergency department by her husband due to severe agitation, confusion, and palpitations that began earlier today. Her husband reports she has been increasingly irritable and has had profuse sweating and watery diarrhea for the past two days. She was diagnosed with a thyroid disorder three years ago but stopped taking her medications six months ago.

Vital signs are temperature 39.8°C (103.6°F), blood pressure 160/90 mm Hg, pulse 155/min and irregularly irregular, and respirations 24/min. Physical examination reveals a distressed, diaphoretic woman. A diffuse, non-tender goiter is palpable. Eye examination shows mild exophthalmos and lid retraction. Neurologic examination is notable for a fine resting tremor and brisk deep tendon reflexes. Electrocardiogram confirms atrial fibrillation with a rapid ventricular response. The patient's clinical presentation is highly consistent with a life-threatening endocrine emergency.

Which of the following pharmacologic interventions should be administered simultaneously as part of the immediate, initial therapeutic regimen? (Select 3)

A $68$-year-old woman is brought to the emergency department from a skilled nursing facility due to altered mental status and fever. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $74/42\text{ mm Hg}$, pulse is $128/\text{min}$, and respiratory rate is $24/\text{min}$. Oxygen saturation is $94\%$ on room air. Physical examination reveals dry mucous membranes and cloudy, malodorous urine in her Foley catheter. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate level of $6.2\text{ mmol/L}$. Blood and urine cultures are obtained, and broad-spectrum intravenous antibiotics are initiated.

Assuming the patient's hemodynamic instability persists despite each consecutive intervention, arrange the following therapies in the correct guideline-concordant sequence for the escalating management of her septic shock.

A $78$-year-old man is evaluated for discharge planning. He was admitted one week ago for fever and severe localized lower back pain and was subsequently diagnosed with methicillin-susceptible *Staphylococcus aureus* (MSSA) vertebral osteomyelitis of L3-L4. He has been treated with intravenous cefazolin. He is now afebrile, hemodynamically stable, and his back pain has significantly improved. He requires an additional five weeks of intravenous antibiotic therapy. His medical history is significant for hypertension and moderate Alzheimer dementia. Prior to admission, he lived alone, and his son visited on weekends to help with chores. The patient is able to ambulate independently with a cane, which is his baseline, and is independent in basic activities of daily living such as eating and dressing. However, he is oriented only to person, has significant short-term memory deficits, and requires supervision for medication administration. Which of the following is the most appropriate disposition for this patient?

A 50-year-old man comes to the clinic to establish care. He has not been evaluated by a healthcare provider in 15 years and has not received any routine medical care or screenings during this time. He generally feels well and takes no medications. He smokes 1 pack of cigarettes daily for the past 30 years and drinks 2 to 3 alcoholic beverages on weekends. He is sexually active with men and uses condoms inconsistently. His BMI is 25 kg/m². Vital signs are within normal limits. Physical examination reveals no abnormalities.

Which of the following preventive interventions are indicated for this patient at this visit? (Select all that apply)

A 28-year-old man is brought to the emergency department by emergency medical services 15 minutes after sustaining a stab wound to the left chest during an altercation. The wound is located at the left 5th intercostal space, just medial to the midclavicular line. On arrival, he is lethargic but responsive to painful stimuli. His temperature is 36.8°C (98.2°F), blood pressure is 76/40 mmHg, pulse is 132/min, and respirations are 26/min. Physical examination reveals distended jugular veins. The trachea is midline, and breath sounds are clear and equal bilaterally. Heart sounds are muffled. Which of the following procedural and management interventions are immediately indicated for this patient? (Select all that apply)

A $71$-year-old woman presents to her primary care physician for a scheduled medication management visit. She has a documented history of severe postmenopausal osteoporosis, which was complicated by a painful $L2$ vertebral compression fracture two years ago. At that time, a dual-energy x-ray absorptiometry (DEXA) scan revealed a T-score of $-3.5$ at the lumbar spine, and she was subsequently initiated on daily subcutaneous teriparatide therapy. She has been fully compliant with the medication and reports no new bone pain, back pain, or falls. Today marks exactly $24$ months of continuous teriparatide treatment.

Current laboratory studies:
Calcium: $9.5 \text{ mg/dL}$
Phosphorus: $3.6 \text{ mg/dL}$
Creatinine: $0.8 \text{ mg/dL}$
Alkaline phosphatase: $115 \text{ U/L}$
$25$-hydroxyvitamin D: $45 \text{ ng/mL}$

A repeat DEXA scan performed this week demonstrates a T-score of $-2.3$ at the lumbar spine and $-2.5$ at the total hip.

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

An 58-year-old male resident of an assisted living facility is evaluated in the emergency department due to a two-day history of frequent falls and worsening gait unsteadiness. Staff members also note that he has become increasingly confused. His medical history includes post-traumatic epilepsy, heart failure, and decompensated cirrhosis. His current medications are phenytoin, spironolactone, furosemide, and lactulose. He reports adhering to his regimen and has two to three soft bowel movements daily. On physical examination, he is alert but disoriented to time and place. Neurologic evaluation reveals prominent horizontal nystagmus on bilateral lateral gaze and a broad-based, unsteady gait. Asterixis is absent.

Laboratory results are as follows:

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

During morning rounds in the medical intensive care unit, a $24$-year-old man is evaluated. He was admitted $18$ hours ago with severe diabetic ketoacidosis. He has received aggressive fluid resuscitation and a continuous intravenous regular insulin infusion. Currently, he is asymptomatic, alert, and requesting breakfast. His most recent basic metabolic panel demonstrates a serum bicarbonate of $21\text{ mEq/L}$ and an anion gap of $10\text{ mEq/L}$. Venous pH is $7.34$. Point-of-care blood glucose is $175\text{ mg/dL}$. The care team decides it is time to transition him to a maintenance regimen of subcutaneous glargine and lispro insulin. Arrange the following steps in the most appropriate chronological sequence to safely accomplish this therapeutic transition.

An intensive care unit team assumes care of a 32-year-old male who was admitted overnight following an intentional overdose. Paramedics found empty prescription bottles for amitriptyline and clonazepam near him. The patient was intubated for airway protection shortly after arrival. Despite the administration of 3 liters of intravenous lactated Ringer solution over the past four hours, his blood pressure remains 76/40 mm Hg. His heart rate is 134/min. Physical examination is notable for widely dilated pupils, dry oral mucosa, and absent bowel sounds. The continuous cardiac monitor displays sinus tachycardia. A stat 12-lead electrocardiogram confirms a QRS duration of 152 ms, a prominent terminal R wave in lead aVR, and a QTc interval of 518 ms. Which of the following pharmacologic interventions are appropriate at this time? (Select all that apply)

A 68-year-old man with a history of ischemic cardiomyopathy (left ventricular ejection fraction 25%) and paroxysmal atrial fibrillation presents to the cardiology clinic for follow-up. Over the past month, he has experienced progressive fatigue and frequent palpitations. His current medications include sacubitril-valsartan, carvedilol, eplerenone, dapagliflozin, and apixaban. Vital signs today are within normal limits except for an irregular pulse of 118/min. An electrocardiogram confirms atrial fibrillation with a rapid ventricular response. Given his heavy symptomatic burden and underlying structural heart disease, the physician decides to initiate oral amiodarone for rhythm control. Which of the following baseline diagnostic studies are strictly indicated prior to or shortly after initiating this medication? (Select exactly 3 options)

A 76-year-old woman is brought to the emergency department due to the sudden onset of severe abdominal pain that started 3 hours ago. Her medical history includes hypertension, hyperlipidemia, and paroxysmal atrial fibrillation. She stopped taking her prescribed apixaban one week ago prior to a dental extraction and did not resume it. Her temperature is 38.2°C (100.8°F), blood pressure is 82/50 mm Hg, pulse is 128/min and irregular, and respirations are 26/min. On physical examination, the abdomen is distended with board-like rigidity, diffuse tenderness to palpation, and marked rebound tenderness. Bowel sounds are absent.

The patient is immediately started on aggressive intravenous fluid resuscitation, broad-spectrum antibiotics, and an intravenous heparin infusion. Which of the following is the most appropriate next step in the management of this patient?