All practice questions

For the following adult patients receiving end-of-life care, identify the most appropriate targeted pharmacologic therapy to manage their acute distressing symptoms.

A 61-year-old man is evaluated in the intensive care unit. He was admitted 14 days ago for severe necrotizing pancreatitis. On hospital day 8, he developed a deep venous thrombosis and was started on an unfractionated heparin infusion. Three days later, his platelet count dropped from $240,000/\text{mm}^3$ to $85,000/\text{mm}^3$. A serotonin release assay was positive, confirming heparin-induced thrombocytopenia (HIT). All heparin products were discontinued, and a continuous intravenous infusion of argatroban was initiated.

The patient's clinical condition has since stabilized. Three days ago, oral warfarin was initiated for long-term anticoagulation. Today, his platelet count has recovered to $175,000/\text{mm}^3$.

The target INR for this patient's long-term management is 2.0 to 3.0.

Which of the following are appropriate steps in the ongoing monitoring and therapeutic evaluation for this patient? (Select all that apply)

During morning rounds on the medical ward, the care team discusses the transition plan for a 68-year-old woman. She has been hospitalized for two weeks after presenting with severe sepsis from a perforated diverticulum. Her initial course required an emergent exploratory laparotomy, colostomy creation, and a 10-day intensive care unit stay complicated by acute respiratory distress syndrome that required mechanical ventilation.

She was extubated three days ago and transferred to the floor. Her vital signs are temperature 37.1°C (98.8°F), blood pressure 124/78 mmHg, pulse 80/min, and respirations 16/min. She is breathing comfortably on room air. The surgical incision is healing appropriately, and the colostomy is functioning well.

A physical therapy assessment reveals profound generalized muscle weakness consistent with critical illness polyneuropathy. The patient requires maximum physical assistance from two staff members to transfer from the bed to a chair and cannot bear weight independently. Despite being highly motivated to recover, she becomes visibly exhausted after 30 to 45 minutes of combined physical and occupational therapy. Prior to admission, she lived at home with her husband, who suffers from advanced heart failure and relies on a wheelchair.

What is the most appropriate disposition for this patient?

A $54$-year-old male is evaluated on hospital day $4$ for altered mental status. He was originally admitted for severe alcohol withdrawal complicated by generalized tonic-clonic seizures. The patient was successfully stabilized with intravenous lorazepam followed by a loading dose of phenytoin, and he is currently receiving an oral phenytoin maintenance regimen. His medical history is significant for severe alcohol use disorder and decompensated cirrhosis. Today, the nursing staff notes that the patient is increasingly confused, lethargic, and dysarthric. When attempting to walk to the bathroom, he exhibited a wide-based, unsteady gait. Vital signs are within normal limits. Neurologic examination reveals prominent bilateral horizontal nystagmus. Asterixis is absent. Laboratory studies show the following:

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

A 48-year-old man with advanced amyotrophic lateral sclerosis is admitted to the hospital with severe aspiration pneumonia and acute hypercapnic respiratory failure. On evaluation, he is lethargic, oriented only to person, and lacks medical decision-making capacity. The patient has a legally valid advance directive, executed two years ago while he had full capacity, which explicitly states, "I refuse intubation and mechanical ventilation under any circumstances." At that same time, he also designated his husband as his durable power of attorney for healthcare.

The patient's respiratory status worsens, and he is in impending respiratory arrest. His husband, who is at the bedside, becomes highly distressed and tells the physician, "I know what his living will says, but I cannot lose him today. I am his designated proxy, and I demand that you intubate him to save his life."

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

During a routine executive briefing, the chief medical officer highlights a concerning trend of patients leaving the emergency department without being evaluated by a physician. To systematically tackle this throughput failure, the clinical operations committee adopts the Lean Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) framework. Arrange the following committee actions in the correct chronological sequence according to this methodology.

A 31-year-old man with a history of treatment-resistant schizophrenia is evaluated during a routine follow-up visit. He was started on clozapine $6$ weeks ago after failing trials of risperidone, aripiprazole, and haloperidol. He is currently maintained on a stable dose of $300 \text{ mg/day}$. The patient is of Northern European descent. He reports feeling well, with a significant reduction in his auditory hallucinations, and has no fever, chills, sore throat, or malaise. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $122/78 \text{ mmHg}$, and pulse is $82/\text{min}$. Routine laboratory testing reveals a total leukocyte count of $4,200/\mu\text{L}$ and an absolute neutrophil count of $1,350/\mu\text{L}$. Prior to initiating clozapine, his absolute neutrophil count was $3,600/\mu\text{L}$. Which of the following is the most appropriate next step in the management of this patient?

A prospective cohort study evaluates the impact of a novel genetic marker on the development of severe coronary artery disease (CAD) over $10$ years. The incidence of CAD is $10\%$ in the exposed group (marker positive) and $2\%$ in the unexposed group (marker negative). The overall incidence of CAD in the entire study population is $3.6\%$. Match each calculated epidemiological value below to its corresponding measure of association or impact.

Determine the most appropriate validated risk stratification tool used to guide the immediate care setting disposition (e.g., safe outpatient discharge versus hospital admission) for each clinical scenario. Match each patient presentation to its corresponding disposition tool.

A 78-year-old man is evaluated for discharge planning on hospital day 12 following admission for a severe acute ischemic stroke. His hospital course was complicated by aspiration pneumonia, which has now fully resolved after a 7-day course of intravenous antibiotics. His medical history includes moderate chronic obstructive pulmonary disease (COPD) and hypertension.

Currently, the patient is hemodynamically stable and his oxygen saturation is 95% on room air. Neurological examination shows dense left-sided hemiparesis and left homonymous hemianopia. He has moderate oropharyngeal dysphagia but is safely tolerating a mechanical soft diet with thickened liquids.

Physical and occupational therapy evaluations indicate that he requires maximal assistance for bed mobility and transfers from bed to chair. He is cognitively intact, highly motivated, and actively participates in his rehabilitation sessions. However, due to dyspnea from his underlying COPD and generalized deconditioning, he experiences severe exhaustion and can only participate in 60 to 90 minutes of combined therapy per day before requiring prolonged rest.

He lives in a single-story home with his 76-year-old wife, who has severe rheumatoid arthritis and is physically unable to assist with his transfers. The patient has standard Medicare coverage and limited out-of-pocket financial resources.

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

A 28-year-old primigravida at 39 weeks gestation is admitted to the labor and delivery unit in active labor. She requests epidural analgesia. During preparation, a nurse nearly connects the epidural bupivacaine infusion into the patient's peripheral intravenous line due to similar-appearing tubing ports. The error is recognized and intercepted just before administration. In response to this near miss, the department director convenes a multidisciplinary quality and safety team. Rather than solely investigating this specific event, the team is tasked with mapping out the entire process of neuraxial medication administration on the unit. They brainstorm all potential ways the tubing, labeling, and administration steps could fail. The team then assigns numerical scores to each potential failure based on its severity, likelihood of occurrence, and probability of going undetected. The combined scores are used to prioritize the rollout of new, physically incompatible tubing connectors. Which of the following quality improvement methodologies is the team employing?

A $42$-year-old female with a history of bipolar disorder is brought to the emergency department by her family due to progressively worsening lethargy, coarse tremors, and severe ataxia over the past three days. She has been stable on lithium carbonate for five years but was recently prescribed lisinopril for hypertension by her primary care physician. Initial laboratory evaluation reveals a serum lithium concentration of $3.8 \text{ mEq/L}$ and a serum creatinine of $2.4 \text{ mg/dL}$ (baseline $0.9 \text{ mg/dL}$). Arrange the following therapeutic and monitoring actions in the most appropriate chronological sequence for managing this patient's condition.

A 22-year-old woman is brought to the emergency department by her roommate 2 hours after intentionally ingesting an unknown quantity of acetaminophen. She is currently asymptomatic. Her vital signs are within normal limits, and her physical examination is unremarkable. Intravenous access is established. Arrange the following steps in the most appropriate chronological order for evaluating and monitoring this patient's potential acetaminophen toxicity.

A prospective cohort study is conducted to evaluate the association between the regular use of a novel synthetic oral glucocorticoid and the development of avascular necrosis (AVN) of the femoral head. The study follows $4,000$ patients prescribed the new glucocorticoid and $6,000$ patients prescribed standard nonsteroidal anti-inflammatory drugs (NSAIDs) for similar rheumatologic conditions. Over a $10$-year follow-up period, $160$ patients in the glucocorticoid group and $60$ patients in the NSAID group develop AVN.

Based on these findings, what percentage of the AVN cases in the glucocorticoid group is theoretically attributable to the use of the new drug?

An 82-year-old woman is evaluated for discharge planning. She was admitted 4 days ago for an acute kidney injury secondary to poor oral intake and dehydration, which has fully resolved with intravenous fluids. During the hospitalization, the medical team notes significant cognitive deficits. A Montreal Cognitive Assessment (MoCA) score is 15/30. Her daughter, who lives in another state and cannot provide direct care, arrives and reports that the patient has recently been getting lost in her own neighborhood, forgetting to pay bills, and leaving the stove burner on unattended. The patient currently lives alone in a single-story house.

Physical and occupational therapy evaluations determine that the patient is independently ambulatory without an assistive device. She is physically capable of transferring, bathing, and dressing herself, although she requires frequent verbal cueing to initiate and complete these tasks. She takes only oral medications for hypertension and hypothyroidism. She does not require any intravenous medications, wound care, or ongoing physical therapy. Both the patient and her daughter agree that the patient can no longer safely live alone and wish to transition her to an appropriate facility.

Which of the following is the most appropriate care setting for this patient's disposition?

A primary care physician is reviewing the electronic health records of four established patients who are scheduled for annual health maintenance visits this morning. Match each patient's specific clinical presentation to the single most appropriate, guideline-concordant screening intervention that should be ordered or performed today.

A $38$-year-old male nurse is evaluated during a routine follow-up visit. Six weeks ago, he was diagnosed with latent tuberculosis infection after routine occupational screening revealed a positive interferon-gamma release assay. A chest radiograph at that time was normal. He was started on a daily regimen of isoniazid and pyridoxine. Prior to initiating therapy, his baseline hepatic transaminase levels and bilirubin were within normal limits.

Today, he reports that he feels well, exercises three times a week, and has no fatigue, nausea, vomiting, or abdominal pain. He drinks one glass of wine occasionally but has not consumed any alcohol in the past two weeks. Physical examination shows an anicteric patient with a non-tender abdomen and no hepatomegaly.

Current laboratory studies are as follows:

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

An asymptomatic 67-year-old woman visits her primary care physician to review her preventive health needs. Her past medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy performed 12 years ago for cervical intraepithelial neoplasia grade 3 (CIN 3). She takes amlodipine daily.

She has a 54 pack-year smoking history but successfully quit 16 years ago. She consumes a glass of wine on weekends and denies any illicit drug use.

Her records indicate the following recent preventive evaluations:
- Screening colonoscopy at age 61 revealed no polyps.
- Screening mammography 6 months ago was interpreted as normal (BI-RADS 1).
- Dual-energy x-ray absorptiometry scan at age 65 showed a T-score of -1.4 at the lumbar spine and -1.2 at the femoral neck.
- Her most recent vaginal cuff cytology combined with human papillomavirus co-testing was performed 4 years ago and was negative.
- She received the 20-valent pneumococcal conjugate vaccine and a two-dose recombinant zoster vaccine series at age 65. She had her annual influenza vaccination 1 month ago.

Physical examination today is unremarkable. Her blood pressure is 128/78 mmHg, and her body mass index is 26 kg/m².

Which of the following is the most appropriate next step in this patient's preventive care?

A $45$-year-old man comes to the clinic for a routine follow-up visit. Four weeks ago, he was diagnosed with active pulmonary tuberculosis and started on a daily regimen of isoniazid, rifampin, pyrazinamide, and ethambutol, along with pyridoxine. He reports feeling much better, with resolution of his initial fever, night sweats, and cough. He specifically denies any abdominal pain, nausea, vomiting, dark urine, or unusual fatigue. He has no history of liver disease and does not consume alcohol. Vital signs are within normal limits. Physical examination shows no scleral icterus, and the abdomen is soft and non-tender with no hepatomegaly.

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

A regional hospital plans to expand the use of continuous intravenous insulin infusions to its intermediate care medical wards, a practice that was previously restricted to the intensive care unit. Given the high-risk nature of intravenous insulin, the chief quality officer convenes a multidisciplinary team before the new policy is implemented. The team systematically maps out the proposed new workflow, from the initial physician order to nurse administration and blood glucose monitoring. At each step, they brainstorm how the process might fail, evaluate the potential clinical consequences of such a failure, and calculate a risk priority number. This analysis is then used to design safety constraints prior to the program's official launch. Which of the following best describes the methodology this team is utilizing?