All practice questions

Paramedics transport a 68-year-old male to the emergency room due to progressive, profound weakness over the past 24 hours. The patient has a background of ischemic cardiomyopathy and stage IV chronic kidney disease. Current outpatient medications comprise lisinopril, spironolactone, and carvedilol. Initial triage vital signs demonstrate a pulse of 42/min and a blood pressure of 105/60 mmHg. A 12-lead electrocardiogram displays a sine wave pattern with widened QRS complexes and prominently peaked T waves. A point-of-care basic metabolic panel is notable for a potassium concentration of 8.2 mEq/L. Arrange the following pharmacologic therapies in the correct chronological order for the acute management of this presentation.

A 24-year-old man with type 1 diabetes mellitus is admitted to the intensive care unit for the management of diabetic ketoacidosis precipitated by viral gastroenteritis. He has been receiving aggressive intravenous fluid resuscitation, potassium supplementation, and a continuous regular insulin infusion. Eighteen hours after admission, he is alert, reports feeling hungry, and has no nausea. Current laboratory studies show a serum glucose of $165 \text{ mg/dL}$, a serum bicarbonate of $18 \text{ mEq/L}$, an anion gap of $10 \text{ mEq/L}$, and a venous pH of $7.34$. The physician determines the patient is ready to transition to a subcutaneous insulin regimen. Arrange the following steps in the correct chronological sequence to safely de-escalate therapy and establish ongoing monitoring.

An ambulatory infectious disease clinic evaluates a 45-year-old male patient who recently received a diagnosis of active cavitary pulmonary tuberculosis. His initial sputum acid-fast bacilli (AFB) smear is positive, and rapid molecular testing has confirmed the presence of a pan-susceptible Mycobacterium tuberculosis isolate. As he prepares to commence standard antituberculous pharmacotherapy, the clinical team formulates his longitudinal care plan.

Arrange the following steps representing the appropriate monitoring and treatment evaluation protocol for this patient in the correct chronological sequence.

A physician is evaluating a 67-year-old male patient who reports a nagging, dry cough persisting for three months. The patient, who has a 45-pack-year history of cigarette smoking, denies hemoptysis, night sweats, or unintentional weight loss. His past medical history includes essential hypertension and mild chronic obstructive pulmonary disease. Auscultation of the lungs reveals globally decreased breath sounds without focal adventitious sounds. An initial posteroanterior and lateral chest radiograph is obtained, revealing an incidental 2.2-cm, irregularly shaped, noncalcified density in the apical region of the right lung.

Arrange the following diagnostic interventions in the correct sequential order to properly work up this patient's pulmonary finding, beginning with the immediate next best step.

A 54-year-old male is preparing for transfer to a skilled nursing facility (SNF) following a prolonged 28-day hospitalization for necrotizing pancreatitis. His hospital course was complicated by critical illness polyneuropathy and newly insulin-dependent diabetes mellitus. The multidisciplinary team has cleared him for discharge, and the case manager has secured an available bed at the SNF for today.

To ensure a safe care transition and adhere to standardized patient handoff protocols, arrange the following transitional care steps in the most appropriate chronological sequence.

A 27-year-old man is brought to the emergency department after a high-speed motorcycle collision. On arrival, he is obtunded, and his airway is immediately secured via endotracheal intubation. Vital signs are temperature 34.8°C (94.6°F), heart rate 145/min, and blood pressure 65/40 mmHg. Breath sounds are equal bilaterally, and a portable chest radiograph is unremarkable. The pelvis is mechanically stable. An extended focused assessment with sonography for trauma (eFAST) scan shows a large amount of free fluid in the hepatorenal and splenorenal spaces, with no pericardial effusion. A massive transfusion protocol is initiated.

Arrange the following surgical and procedural interventions in the most appropriate chronological order for this patient's definitive management.

A 68-year-old retired teacher is admitted to the cardiac telemetry unit for the elective initiation of dofetilide to maintain normal sinus rhythm after a recent electrical cardioversion for symptomatic atrial fibrillation. He has a history of hypertension and ischemic cardiomyopathy. His home medications include lisinopril, metoprolol succinate, and apixaban. His vital signs are stable, and the physical examination is unremarkable. The care team is planning the mandatory safety protocol for initiating this antiarrhythmic therapy.

Arrange the following clinical steps in the correct chronological sequence for the initiation, monitoring, and evaluation of dofetilide therapy in this patient.

A patient is currently receiving treatment in the cardiovascular step-down unit for a massive pulmonary embolism diagnosed three days ago. She was initially started on an unfractionated heparin infusion. Today, her daily laboratory monitoring reveals a precipitous drop in her platelet count. She has also developed a new, painful, swollen right calf.

A serotonin release assay is sent, and a clinical diagnosis of heparin-induced thrombocytopenia (HIT) with a new deep vein thrombosis is suspected.

Arrange the following management and monitoring steps in the correct chronological sequence to appropriately treat this patient's condition and safely transition her to long-term oral anticoagulation with warfarin.

A 73-year-old retired pilot arrives at the emergency department accompanied by his wife, complaining of a sudden, agonizing pain across his entire abdomen that started approximately 90 minutes ago. He has a known medical history of heart failure with preserved ejection fraction and paroxysmal atrial fibrillation, for which he has been poorly compliant with his prescribed anticoagulant therapy. Shortly before leaving his house, he passed a large amount of dark red blood from his rectum. Vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 162/94 mmHg, heart rate of 122/min with an irregularly irregular rhythm, and respiratory rate of 22/min. On physical examination, the patient appears in severe distress, writhing on the stretcher. However, his abdomen is soft, non-distended, and only mildly tender to deep palpation without any rebound tenderness, guarding, or rigidity. Bowel sounds are hypoactive. Arrange the following differential diagnoses from the MOST likely (highest pre-test probability) to the LEAST likely (lowest pre-test probability) based on this patient's clinical presentation.

A 78-year-old man is being prepared for discharge after a 12-day hospitalization for urosepsis. Upon admission, his temperature was 38.9°C (102.0°F), blood pressure was 85/50 mm Hg, and serum creatinine was 3.2 mg/dL. He responded well to intravenous fluids and antibiotics; current vitals are temperature 37.1°C (98.8°F), blood pressure 122/76 mm Hg, and heart rate 78/min. His serum creatinine has improved to 1.8 mg/dL. Despite medical stabilization, his functional status has declined, requiring the assistance of two people for transfers. Furthermore, his cognitive status continues to fluctuate with new-onset delirium, and a formal assessment reveals he currently lacks medical decision-making capacity. The care team is initiating the discharge process. Arrange the following critical steps in this patient's transition of care in the most appropriate chronological order to ensure a safe, legally sound, and comprehensive disposition.

A 62-year-old man is recovering on the general medical floor after a three-week hospitalization for severe sepsis secondary to ascending cholangitis. He initially required vasopressor support and mechanical ventilation but is now hemodynamically stable, afebrile, and breathing comfortably on room air. Due to significant intensive care unit-acquired weakness, he cannot perform basic activities of daily living independently. The primary internal medicine team determines that he requires transfer to a skilled nursing facility (SNF) for comprehensive physical and occupational therapy prior to returning home.

Arrange the following essential steps of this care transition process in the most appropriate chronological sequence to ensure patient safety and minimize the risk of readmission.

An established 38-year-old female patient presents for follow-up regarding resistant hypertension. She reports experiencing profound muscle cramps and episodic weakness over the last month. Clinical assessment reveals a blood pressure of 168/102 mm Hg, which has remained uncontrolled despite strict adherence to maximum tolerated doses of lisinopril, amlodipine, and hydrochlorothiazide. A basic metabolic panel highlights a serum potassium level of 2.8 mEq/L. Suspecting primary hyperaldosteronism, the physician tapers her interfering medications, transitions her to doxazosin, and normalizes her potassium. Arrange the subsequent diagnostic investigations in the correct chronological order, proceeding from the initial diagnostic step to the definitive pre-surgical assessment.

A $62$-year-old man with a $10$-year history of type 2 diabetes mellitus returns to the clinic for a routine follow-up. His current medication regimen includes maximum tolerated doses of metformin, empagliflozin, and a glucagon-like peptide-1 (GLP-1) receptor agonist. His hemoglobin A1c today is $9.5\%$, and his home fasting blood glucose levels consistently range between $180$ and $220\text{ mg/dL}$. The physician and patient agree that initiating insulin therapy is the most appropriate next step. Arrange the following steps in the correct chronological sequence for intensifying and monitoring this patient's insulin therapy over the coming months according to standard diabetes care guidelines.

A 62-year-old woman is brought to the emergency department by her family due to a 2-day history of progressively worsening severe right-sided abdominal pain, high fever, and new-onset confusion. Her past medical history is significant for hypertension and hyperlipidemia. On arrival, her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $84/52\text{ mm Hg}$, heart rate is $122/\text{min}$, and respiratory rate is $24/\text{min}$. Physical examination reveals marked scleral icterus, dry mucous membranes, and significant tenderness to palpation in the right upper quadrant without rebound or guarding. The patient is lethargic and disoriented to time and place. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$, a total bilirubin of $6.2\text{ mg/dL}$, direct bilirubin of $4.8\text{ mg/dL}$, and an alkaline phosphatase of $450\text{ U/L}$. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 78-year-old woman with a history of congestive heart failure and chronic kidney disease is hospitalized for a severe heart failure exacerbation. After a 5-day stay, she has reached clinical stability. The interdisciplinary team is preparing her for transition to a skilled nursing facility (SNF) for subacute rehabilitation. To ensure patient safety, prevent medication errors, and minimize readmission risk, arrange the following steps of the transitions-of-care pathway in the correct chronological sequence according to standard safe discharge practices.

A 52-year-old woman is hospitalized for a massive pulmonary embolism and treated with a continuous unfractionated heparin infusion. On hospital day $6$, her platelet count decreases from an admission baseline of $260,000/\text{mm}^3$ to $85,000/\text{mm}^3$. She subsequently reports acute left lower extremity pain, and a duplex ultrasound confirms a new deep vein thrombosis. Her clinical presentation yields a 4T score indicating a high probability of heparin-induced thrombocytopenia (HIT). Arrange the following therapeutic management and monitoring steps in the correct chronological sequence.

A $22$-year-old woman is brought to the emergency department $2$ hours after intentionally ingesting a large, unknown quantity of acetaminophen tablets. She is currently asymptomatic, with normal vital signs and an unremarkable physical examination. Arrange the following steps in the most appropriate chronological sequence for monitoring, evaluating, and managing this patient's overdose according to standard medical protocols.

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 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 $68$-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.