All practice questions

During a comprehensive intake evaluation at a new primary care practice, a physician assesses a 61-year-old male patient who has lacked medical follow-up for the past eight years. His past medical history includes type 2 diabetes mellitus, currently managed with diet and metformin. The patient reports a history of smoking one pack of cigarettes daily starting at age 20, but he successfully quit 11 years ago and has abstained since. He denies alcohol or recreational drug use. Blood pressure is 128/82 mmHg, and body mass index is 28 kg/m². A recent basic metabolic panel and hemoglobin A1c (6.7%) are stable. The physician is planning his health maintenance schedule. Which of the following preventive interventions are indicated for this patient today? (Select all that apply)

A hospital quality improvement committee is designing a prospective intervention study to reduce catheter-associated urinary tract infections (CAUTIs) in the intensive care unit. They plan to compare a new silver-alloy catheter to the standard silicone catheter. A priori power analysis determines that 108 patients per intervention group are required to achieve a statistical power of $80\%$ ($\beta = 0.20$) at a significance level of $\alpha = 0.05$ to detect a clinically meaningful reduction in CAUTI incidence. Based on prior hospital initiatives, the committee anticipates a $20\%$ loss of analyzable data due to early patient transfers or incomplete electronic health records.

To ensure the study maintains the desired $80\%$ power, what is the minimum total number of patients the committee must initially enroll across both groups combined?

A 31-year-old male architect presents to the infectious disease clinic to discuss the results of recent blood work. He recently tested positive for HIV, and subsequent flow cytometry revealed a CD4 T-lymphocyte count of $410 \text{ cells/mm}^3$. The physician advises starting a daily antiretroviral regimen. The patient shakes his head and states, "I run marathons and have never felt better. I saw on a forum that these drugs destroy your liver and cause horrible fatigue. There is no way I am starting them until I actually feel ill." Which of the following is the most appropriate initial response by the physician?

A physician is training medical residents on the use of Motivational Interviewing (MI) techniques for lifestyle modification counseling. The core skills of MI are often summarized by the acronym OARS. Match each of the physician's verbal statements provided below with the specific MI communication technique it best represents.

A 62-year-old woman is evaluated in the intensive care unit for persistent oozing from her intravenous catheter sites. She was admitted two days ago with sepsis secondary to ascending cholangitis. She has a history of primary biliary cholangitis and cirrhosis. Current medications include broad-spectrum intravenous antibiotics and vasopressors. Vital signs show a temperature of $38.2^\circ\text{C}$, blood pressure of $90/55\text{ mmHg}$, and heart rate of $110/\text{min}$. Laboratory studies show:

Based on these findings, which of the following is the most likely primary cause of this patient's coagulopathy?

A 54-year-old man presents to the clinic to establish care. He has not seen a physician in five years. His medical history includes type 2 diabetes mellitus, hypertension, and stage 3a chronic kidney disease. Current medications include lisinopril, amlodipine, metformin, and empagliflozin. He smoked 1.5 packs of cigarettes daily from age 18 until he quit at age 48. His family history is notable for a father who was diagnosed with colorectal cancer at age 65. The patient's last colonoscopy was at age 49 and showed no polyps. He received an annual influenza vaccine at a local pharmacy three weeks ago. His tetanus-diphtheria-acellular pertussis (Tdap) vaccination is up to date, and he completed the hepatitis B vaccine series in his 30s. He has never received a pneumococcal vaccine or a zoster vaccine. Which of the following combinations of preventive interventions is most appropriate for this patient today?

A 61-year-old postmenopausal woman presents to the ambulatory clinic for an annual wellness visit. She has not seen a physician in three years. Medical history is significant for mild hypertension and gastroesophageal reflux disease. Current medications include amlodipine and pantoprazole. Social history is notable for smoking 10 cigarettes a day (25-pack-year history) and drinking 1-2 glasses of wine on weekends. Her mother suffered a femoral neck fracture at age 76. Her preventive care history includes a normal screening mammogram and normal cervical cytology with human papillomavirus (HPV) co-testing one month ago at a health fair. Her last screening colonoscopy was normal at age 55. Physical examination reveals a blood pressure of 128/82 mm Hg, heart rate of 72/min, and a body mass index (BMI) of 22 kg/m². The remainder of the examination is unremarkable. The patient asks if she should be tested for osteoporosis. According to current guidelines, which of the following is the most appropriate next step regarding osteoporosis screening for this patient?

An attending physician is evaluating a hospitalized patient who has developed worsening lower extremity edema and frothy urine. Initial laboratory studies reveal a serum albumin level of $1.5$ g/dL. A basic metabolic panel is obtained concurrently, which demonstrates a measured total serum calcium level of $6.8$ mg/dL. Assuming a standard reference albumin value of $4.0$ g/dL for calculation purposes, what is this patient's corrected total serum calcium concentration?

A primary care network is planning a randomized controlled trial to evaluate a novel pharmacist-led telehealth coaching program. The goal is to reduce systolic blood pressure among adult patients with uncontrolled hypertension. The primary outcome is the mean change in systolic blood pressure at 6 months. Preliminary calculations indicate the study will have 70% power to detect a $4\text{ mmHg}$ difference between the intervention and standard care groups, assuming a standard deviation of $12\text{ mmHg}$ and a two-sided significance level ($\alpha$) of 0.05. The trial steering committee dictates that the statistical power must be at least 80% before recruitment begins. Which of the following modifications to the trial design or statistical plan would individually increase the statistical power of the study? (Select all that apply)

Match each adult patient presenting for a health maintenance or prenatal visit with the most appropriate next step in preventive care based on current guidelines.

Four adult patients hospitalized with respiratory symptoms undergo thoracentesis for newly discovered pleural effusions. Based on Light's criteria and the accompanying specialized fluid analyses, match each patient's pleural fluid (PF) profile to the most likely underlying etiology.

A physician is evaluating a 46-year-old man during a routine wellness examination. The patient's past medical history is significant for pancolonic ulcerative colitis diagnosed 12 years ago. His gastrointestinal disease is currently in deep clinical remission, maintained solely on scheduled infliximab infusions. He reports smoking one pack of cigarettes daily for the past 25 years. Due to a prolonged period of uninsurance, he has not undergone any preventive health screenings or received any immunizations over the past decade. Today, he feels well and reports no acute symptoms. Which of the following preventive interventions are indicated for this patient? (Select all that apply)

A 32-year-old woman is evaluated in the clinic following a routine wellness examination that revealed an elevated serum calcium level. She has no complaints and reports feeling well. She has no history of nephrolithiasis, bone fractures, or abdominal pain. She takes no medications or over-the-counter supplements. Vital signs are normal. Physical examination is unremarkable.

Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Emergency medical services bring a 62-year-old gentleman to the trauma bay after he collapsed at home. His wife reports that he has been complaining of severe, unremitting abdominal pain for the past 48 hours. His past medical history includes long-standing osteoarthritis, for which he takes high-dose naproxen daily. On presentation, his temperature is 39.1°C (102.4°F), blood pressure is 82/50 mm Hg, pulse is 128/min, and respirations are 24/min. Physical examination reveals a distended, diffusely tender abdomen with rigid, board-like guarding and rebound tenderness. Bowel sounds are absent. An upright chest radiograph reveals free air under the right hemidiaphragm. Which of the following interventions are indicated immediately in this patient's management? (Select all that apply)

A 35-year-old woman is brought to the emergency department by her husband due to severe agitation, confusion, and uncontrollable shivering that began abruptly earlier today. She has a history of treatment-resistant major depressive disorder. Ten days ago, her psychiatrist discontinued her fluoxetine regimen due to lack of efficacy. Three days ago, she was started on tranylcypromine. Her temperature is $39.2^\circ \text{C}$ ($102.6^\circ \text{F}$), blood pressure is $168/98 \text{ mm Hg}$, pulse is $128/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals profuse diaphoresis, mydriasis, and hyperactive bowel sounds. Neurologic examination demonstrates severe lower extremity hyperreflexia and spontaneous clonus. Intravenous fluids and lorazepam are administered, but the patient remains highly agitated and her temperature increases to $39.8^\circ \text{C}$ ($103.6^\circ \text{F}$). Which of the following is the most appropriate next pharmacologic intervention?

A 29-year-old male is brought to the trauma center following a severe crush injury at a construction site. He is confused and pale. Vital signs are HR 142/min, BP 70/40 mm Hg, and RR 26/min. The airway is intact, and breath sounds are equal bilaterally. A focused assessment with sonography for trauma (FAST) exam shows no pericardial or intraperitoneal fluid. A portable chest radiograph is normal. A portable pelvic radiograph reveals a severe diastasis of the pubic symphysis and disruption of the right sacroiliac joint. A pelvic binder is immediately applied, and a massive transfusion protocol is initiated. After receiving 4 units of packed red blood cells, 4 units of fresh frozen plasma, and 1 unit of platelets over the next 20 minutes, the patient's blood pressure remains 72/42 mm Hg. The interventional radiology suite is currently occupied with another emergency, and the team will not be available for at least an hour. Which of the following is the most appropriate next step in the management of this patient?

A 72-year-old female patient with an established diagnosis of polymyalgia rheumatica is evaluated in the emergency department after noticing a sudden, painless loss of vision in her right eye two hours prior to arrival. During the interview, she notes experiencing new-onset right-sided jaw pain when chewing, along with fatigue and low-grade fevers over the preceding week. Visual acuity testing reveals light perception only in the right eye and 20/30 in the left eye. The right pupil exhibits a relative afferent pupillary defect. Fundoscopic examination of the right eye reveals a pale, opaque retina with a prominent cherry-red spot in the macula. Based on the complete clinical presentation and examination findings, arrange the following differential diagnoses for her acute vision loss from highest clinical probability to lowest.

A 66-year-old man is brought to the emergency department by his wife due to a 3-day history of progressively worsening shortness of breath, increased cough, and a change in his sputum from clear to thick, dark yellow. He has a 40-pack-year smoking history and was diagnosed with chronic obstructive pulmonary disease (COPD) five years ago. His home medications include a once-daily umeclidinium-vilanterol inhaler and an albuterol rescue inhaler, which he has used eight times today with minimal relief. He has no other major medical conditions. Temperature is 37.8°C (100.0°F), blood pressure is 146/88 mmHg, pulse is 114/min, and respiratory rate is 26/min. Pulse oximetry shows 88% on room air. The patient is using accessory muscles of respiration. Physical examination reveals a barrel-shaped chest, a prolonged expiratory phase, and diffuse bilateral wheezing. There is no jugular venous distention or lower extremity edema. A chest radiograph reveals hyperinflation without focal consolidation, pneumothorax, or pleural effusion.

Which of the following pharmacologic interventions should be included in the immediate management of this patient? (Select all that apply, indicating hangileri doğrudur)

An 82-year-old woman is evaluated for discharge planning. She was admitted to the hospital 11 days ago for severe community-acquired pneumonia. Upon admission, she had a CURB-65 score of 4, requiring intubation and a 7-day stay in the intensive care unit. She was successfully extubated 4 days ago and transferred to the general medical ward.

Currently, she is awake, alert, and oriented. She reports feeling much better but is profoundly fatigued. Temperature is 37.1°C (98.8°F), blood pressure is 128/76 mm Hg, pulse is 78/min, and respirations are 16/min. Pulse oximetry is 96% on room air. Lungs are clear to auscultation bilaterally.

Laboratory studies show a leukocyte count of 11,200/mm³, decreased from a peak of 24,000/mm³ on admission. Her renal function and electrolytes are within normal limits. She is currently completing a 14-day course of oral antibiotics.

Prior to admission, the patient lived at home with her 84-year-old husband and was independent with all activities of daily living. Currently, she has profound generalized muscle weakness consistent with ICU-acquired weakness. She requires the maximal assistance of two people to transfer from the bed to a chair and cannot feed herself or perform basic grooming. Physical and occupational therapy evaluate her and note that she has excellent potential for functional recovery; however, she completely exhausts after 30 minutes of mild therapeutic exercise and is unable to participate in more intensive therapy sessions at this time.

Her husband, who uses a wheelchair due to severe osteoarthritis, is unable to assist with her physical care. They have no other family members nearby.

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

Following a heavy dinner, a 41-year-old female is brought to the emergency department by her partner due to sudden, unremitting right upper abdominal pain radiating to the right scapula. She reports intense nausea and has vomited twice over the past few hours. She is a non-smoker with a BMI of 34 kg/m² and a history of hypertriglyceridemia. Upon triage, her temperature is 38.5°C (101.3°F), pulse is 112/min, blood pressure is 135/85 mm Hg, and respiratory rate is 18/min. Abdominal examination demonstrates focal tenderness below the right costal margin, which sharply worsens on deep inspiration, causing her to abruptly halt her breath. There are no signs of clinical jaundice. To properly evaluate this patient's acute presentation, which of the following are the most appropriate initial diagnostic tests to order? (Select exactly 3 options)