All practice questions

A 71-year-old man presents to the outpatient clinic for a follow-up appointment four weeks following a hospitalization for new-onset atrial fibrillation. While admitted, oral amiodarone was initiated for maintenance of sinus rhythm. The patient reports feeling well with no palpitations, dyspnea, or chest pain. His current medications include amiodarone, lisinopril, and atorvastatin. Today's electrocardiogram demonstrates normal sinus rhythm with a heart rate of 68/min and a QTc interval of 430 ms. The physician counsels the patient on the necessity of longitudinal follow-up to detect potential medication-induced toxicities. Which of the following evaluations are required as part of routine periodic monitoring for this patient's antiarrhythmic therapy? (Select all that apply)

A $29$-year-old woman presents to the clinic for her first prenatal visit. She is currently at $6$ weeks of gestation based on her last menstrual period. The patient has a $4$-year history of Hashimoto thyroiditis and has been well-controlled on levothyroxine $100$ mcg daily for the past two years. She reports no symptoms of fatigue, cold intolerance, constipation, or weight changes. Her most recent serum thyroid-stimulating hormone (TSH) level obtained $3$ months ago was $1.6$ $\mu$ U/mL (reference range: $0.4-4.0$ $\mu$ U/mL). A home pregnancy test was positive one week ago, and a serum human chorionic gonadotropin level drawn yesterday confirms the pregnancy. Vital signs and physical examination today are unremarkable. Which of the following is the most appropriate next step in the monitoring and management of this patient's thyroid disease?

A 32-year-old man is brought to the emergency department by ambulance due to a generalized tonic-clonic seizure. His partner reports that the abnormal movements started 20 minutes ago and have been continuous without any periods of responsiveness. He has no known medical history. Initial vital signs include a blood pressure of 145/85 mm Hg, heart rate of 118/min, and oxygen saturation of 94% on room air. No medications were administered en route. Two large-bore peripheral intravenous lines are immediately established in the resuscitation bay. Arrange the following pharmacologic interventions in the evidence-based sequence for the escalating management of status epilepticus, from initial abortive therapy to the treatment of super-refractory cases.

An internal medicine physician is called to the bedside of a 24-year-old male patient who is receiving care in the critical care unit for diabetic ketoacidosis. The patient was admitted 14 hours prior and has been treated with continuous intravenous fluids, a regular insulin infusion, and an electrolyte protocol. The nursing staff reports that his vital signs are stable, and he is now awake, conversational, and asking for a meal.

The clinical team determines the patient is ready to transition to a subcutaneous insulin regimen. Arrange the following steps for transitioning therapies and monitoring in the most appropriate chronological sequence.

During a routine follow-up visit, a 62-year-old male patient reports a two-week history of bilateral thigh and shoulder pain accompanied by mild weakness. His medical history is significant for a myocardial infarction 6 months prior, and his current daily medication regimen includes aspirin, metoprolol, lisinopril, and atorvastatin 80 mg. Vital signs are within normal limits. On physical examination, there is noticeable tenderness upon palpation of the quadriceps and deltoid muscles bilaterally, and proximal muscle strength is graded at 4/5.

Laboratory studies are obtained and reveal the following:

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

A 68-year-old man is evaluated in the hospital prior to discharge. He was admitted five days ago for acute decompensated heart failure. Echocardiography performed during the admission showed a left ventricular ejection fraction of 30%. His volume status was optimized with intravenous furosemide. He is now clinically stable and transitioned to an oral regimen consisting of furosemide, carvedilol, dapagliflozin, lisinopril, and spironolactone. He has an appointment to be seen in the outpatient clinic in one week. Which of the following laboratory parameters are most critical to measure at his upcoming clinic visit to monitor for potentially life-threatening adverse effects of his updated medication regimen? (Select all that apply)

A 64-year-old man is currently receiving mechanical ventilation in the intensive care unit following a severe traumatic brain injury. On hospital day 5, he develops a new fever of 39.2°C (102.6°F), an increased requirement for fraction of inspired oxygen (FiO2), and thick, purulent endotracheal secretions. A portable chest radiograph reveals a new left lower lobe consolidation. The patient is hemodynamically stable but exhibits signs of systemic inflammation.

Arrange the following steps in the most appropriate chronological sequence for the diagnostic workup, therapeutic management, and subsequent monitoring of this patient's suspected ventilator-associated pneumonia (VAP).

A 42-year-old woman presents to the emergency department with a 2-day history of high fever, chills, and severe sore throat. She was diagnosed with hyperthyroidism due to Graves' disease 4 weeks ago and was started on methimazole and propranolol. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $110/70$ mm Hg, heart rate is $112$/min, and respiratory rate is $18$/min. Physical examination reveals marked pharyngeal erythema with tonsillar exudates but no neck asymmetry or airway compromise. Laboratory studies show:

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

A 22-year-old woman comes to the dermatology clinic for the management of severe nodulocystic acne. Over the past six months, she has been treated with oral doxycycline and topical benzoyl peroxide, but her condition has worsened. She has deep, painful cystic lesions on her face, back, and chest that are beginning to scar. The physician plans to initiate oral isotretinoin. She has no other medical conditions. Which of the following are essential components of this patient's treatment and monitoring plan? (Select all that apply)

A 58-year-old woman is evaluated in the hospital prior to being transferred from the intensive care unit to the general medical ward. She was admitted 6 days ago for a severe exacerbation of chronic obstructive pulmonary disease. Her treatment during hospitalization has included intravenous methylprednisolone, nebulized bronchodilators, and prophylactic subcutaneous unfractionated heparin. Her respiratory status has significantly improved.

Serial laboratory studies reveal the following platelet counts:

On physical examination today, her vital signs are within normal limits. A new, demarcated, erythematous, and exquisitely tender necrotic skin lesion is noted at a recent heparin injection site on her anterior abdomen. There is no mucosal bleeding or petechiae.

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

During a routine health maintenance examination, a physician evaluates a patient with poorly controlled type 2 diabetes mellitus and new-onset eruptive xanthomas on the extensor surfaces. Fasting laboratory results reveal a serum triglyceride concentration of $1,340 \text{ mg/dL}$. The patient is currently managed with metformin monotherapy and lacks any history of atherosclerotic cardiovascular disease.

Please arrange the following clinical actions in the correct chronological sequence for the management and monitoring of this patient's condition over time.

A 72-year-old man is admitted to the medical ward for treatment of community-acquired pneumonia. On hospital day 2, a covering physician intends to prescribe a standard prophylactic dose of subcutaneous heparin for deep vein thrombosis prevention. In the electronic health record (EHR), the physician types "heparin," sees a drop-down list, and quickly selects the top option. The top option is a continuous intravenous therapeutic heparin infusion protocol. The order is verified by the clinical pharmacist and initiated by the bedside nurse. Twelve hours later, the patient develops a massive retroperitoneal hemorrhage requiring resuscitation and transfer to the intensive care unit.

A patient safety committee is convened to evaluate this sentinel event. A preliminary review reveals that the physician was managing multiple unstable patients and experiencing frequent pager interruptions during order entry.

Which of the following is the most appropriate approach or conclusion for the committee during this investigation?

Evaluate the following complex end-of-life patient presentations and pair each with its most appropriate, symptom-specific intervention.

A 72-year-old man presents to the emergency department with sudden, severe abdominal pain that began 2 hours ago. He rates the pain as 10 on a 10-point scale and describes it as diffuse and unremitting. His medical history is significant for permanent atrial fibrillation, hypertension, and hyperlipidemia. He recently stopped taking his apixaban due to financial constraints. Vital signs are temperature 37.2°C (99.0°F), blood pressure 155/90 mmHg, heart rate 118/min and irregularly irregular, and respiratory rate 22/min. On physical examination, the abdomen is soft and non-distended; there is only mild diffuse tenderness to deep palpation, without rebound or guarding. Laboratory studies show a leukocyte count of 18,500/mm³ and a serum lactate of 4.2 mmol/L. Which of the following is the most appropriate initial imaging study to establish the diagnosis?

A 68-year-old retired architect is brought to the emergency department by her husband after a transient loss of consciousness. She was sitting in a chair reading when she suddenly "blacked out." Her husband witnessed the event and reports she was unresponsive for approximately 20 seconds. She had no preceding palpitations, chest pain, diaphoresis, or nausea. There was no limb jerking or urinary incontinence, and she returned to her baseline mental status immediately upon awakening. Her medical history includes hypertension and hyperlipidemia. Blood pressure is 138/82 mmHg, heart rate is 64/min, and respiratory rate is 14/min. Orthostatic vital signs show no significant changes. Physical examination reveals clear lungs and a 2/6 late-peaking systolic murmur at the right upper sternal border. Neurologic examination is nonfocal. An electrocardiogram demonstrates normal sinus rhythm with left axis deviation and a new right bundle branch block (bifascicular block). Basic metabolic panel and complete blood count are within normal limits. Which of the following diagnostic studies are indicated as the most appropriate concurrent initial steps in this patient's evaluation? (Select exactly 2)

A 42-year-old man is brought to the emergency department by his wife due to confusion, agitation, and shivering that began earlier today. He has a history of major depressive disorder, for which he takes fluoxetine. Three days ago, he was evaluated at an urgent care clinic for a purulent right lower leg wound and was prescribed an oral antibiotic for presumed methicillin-resistant *Staphylococcus aureus* (MRSA) cellulitis. On presentation, his temperature is 39.1°C (102.4°F), blood pressure is 158/94 mm Hg, heart rate is 122/min, and respiratory rate is 22/min. Physical examination reveals an agitated and diaphoretic man. The right lower extremity shows resolving erythema and induration without fluctuance. Neurologic examination is notable for generalized muscle rigidity, brisk deep tendon reflexes (3+ bilaterally), and reproducible bilateral ankle clonus. Bowel sounds are hyperactive. Laboratory studies show a leukocyte count of $11,500/\text{mm}^3$ and a creatine kinase level of $850 \text{ U/L}$. Which of the following is the most likely diagnosis?

A 42-year-old woman is evaluated in the surgical intensive care unit on postoperative day 3 following an uncomplicated laparoscopic Roux-en-Y gastric bypass for severe obesity. Over the past 2 hours, she has developed severe, unremitting epigastric pain, severe restlessness, and shortness of breath. Her temperature is 38.8°C (101.8°F), blood pressure is 82/48 mm Hg, heart rate is 135/min, and respiratory rate is 26/min. Pulse oximetry shows 92% on room air. The patient appears diaphoretic, anxious, and acutely ill. Abdominal examination reveals diffuse tenderness, marked involuntary guarding, and rebound tenderness predominantly in the epigastrium. Bowel sounds are absent. Urine output has been 10 mL over the last 2 hours. Laboratory studies show a leukocyte count of 19,000/mm³ with 15% band forms and a serum lactate level of 4.2 mmol/L. She is given a rapid intravenous infusion of 2 L of isotonic crystalloid, after which her blood pressure is 86/52 mm Hg. Which of the following is the most appropriate next step in management?

Patients presenting with acute or subacute hepatic injury require a broad differential diagnosis that incorporates demographics, comorbidities, medication history, and specific laboratory patterns. Match each patient's clinical presentation to the most appropriate initial diagnosis on the differential.

A 54-year-old woman with severe, seropositive rheumatoid arthritis is evaluated in the rheumatology clinic. She continues to experience active synovitis in multiple metacarpophalangeal and proximal interphalangeal joints despite a 6-month trial of optimized methotrexate and a subsequent 4-month trial of etanercept. The physician decides to initiate intravenous tocilizumab. Her medical history is otherwise unremarkable. Baseline screening for latent tuberculosis and viral hepatitis is negative. Which of the following laboratory evaluations are required as part of the specific baseline and ongoing monitoring for this pharmacotherapy? (Select all that apply)

A primary care physician is evaluating a 71-year-old female during an annual wellness examination. The patient's past medical history is significant for postmenopausal osteoporosis. She was diagnosed 5 years ago after a screening dual-energy x-ray absorptiometry (DEXA) scan showed a femoral neck T-score of -2.8. Following the diagnosis, she began therapy with oral risedronate, which she has taken consistently without any gastrointestinal side effects. She has no history of clinical or radiographic fractures. A DEXA scan completed 3 days ago reports a current femoral neck T-score of -2.1. Her daily routine includes walking two miles, and she takes over-the-counter cholecalciferol and calcium carbonate. Renal function and serum calcium are within normal limits. She inquires about her future medication plan. Which of the following is the most appropriate next step in management?