All practice questions

A 28-year-old woman arrives at the emergency department due to severe, progressive right lower quadrant abdominal pain over the past 12 hours, accompanied by nausea and vomiting. Vital signs show a temperature of 38.3°C (100.9°F), blood pressure of 112/72 mmHg, and pulse of 105/min. Physical examination demonstrates localized rigidity and rebound tenderness in the right lower quadrant. A complete blood count reveals a leukocyte count of 16,000/mm³. Cross-sectional imaging of the abdomen and pelvis confirms acute, uncomplicated appendicitis. The surgical team schedules an urgent laparoscopic appendectomy. Which of the following interventions are appropriate in the immediate preoperative management of this patient? (Select all that apply)

Evaluation is underway for a patient hospitalized on the medical ward who is recovering from an exacerbation of chronic obstructive pulmonary disease. The patient, who has a past medical history of heart failure with preserved ejection fraction, paroxysmal atrial fibrillation, and major depressive disorder, was initially treated with intravenous methylprednisolone and continuous nebulized albuterol. His symptoms have significantly improved, and he is now breathing comfortably on room air.

His home medications, which were continued during the admission, include diltiazem, apixaban, escitalopram, and atorvastatin. Morning laboratory results are notable for a serum potassium level of $3.1 \text{ mEq/L}$ and a serum magnesium level of $1.6 \text{ mg/dL}$. A routine 12-lead electrocardiogram performed today shows normal sinus rhythm with a QTc interval of $530 \text{ milliseconds}$. Before the planned discharge, a sputum polymerase chain reaction panel returns positive for Mycoplasma pneumoniae, prompting the decision to initiate targeted oral antibiotic therapy.

Which of the following is the most appropriate antimicrobial regimen to prescribe for this patient?

A 62-year-old man is brought to the emergency department by emergency medical services (EMS) due to the sudden onset of difficulty breathing, facial swelling, and a diffuse pruritic rash. The symptoms began 15 minutes ago while he was eating at a seafood restaurant. His medical history is significant for hypertension, coronary artery disease, and heart failure with preserved ejection fraction. His home medications include lisinopril, metoprolol, aspirin, and atorvastatin. Upon arrival, his blood pressure is 74/40 mm Hg, pulse is 62/min, and oxygen saturation is 90% on room air. Physical examination reveals marked angioedema of the lips, widespread urticaria, and diffuse bilateral expiratory wheezing. EMS has established peripheral intravenous access.

Arrange the following pharmacologic interventions in the correct sequential order of administration for the acute escalation of therapy in this patient.

A 67-year-old man comes to the cardiology clinic for a follow-up evaluation. Over the past 6 months, he has experienced four episodes of severe palpitations, shortness of breath, and fatigue, each lasting up to 12 hours. He has a history of hypertension, type 2 diabetes mellitus, and paroxysmal atrial fibrillation. Current medications include metoprolol succinate, apixaban, rosuvastatin, and lisinopril. His blood pressure is $132/82$ mmHg, and his pulse is $78$/min and irregularly irregular. An electrocardiogram confirms atrial fibrillation with a ventricular rate of $76$/min. The patient is highly symptomatic during his episodes, and after discussing the risks and benefits, the physician decides to initiate oral amiodarone for rhythm control. Which of the following parameters should be evaluated prior to initiating this therapy? (Select all that apply)

A 62-year-old woman is evaluated in the emergency department for right lower extremity swelling and pain that began 2 days ago. Her past medical history is significant for hypertension, type 2 diabetes mellitus, and end-stage renal disease requiring hemodialysis three times a week. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 142/86 mmHg, pulse of 88/min, and respiratory rate of 14/min. Physical examination reveals a swollen, tender, and erythematous right calf. A comprehensive metabolic panel is notable for a blood urea nitrogen of 42 mg/dL and a serum creatinine of 5.8 mg/dL. Compression ultrasonography of the right lower extremity demonstrates a noncompressible right popliteal vein. Which of the following is the most appropriate initial pharmacologic intervention for this patient?

A 72-year-old man comes to the clinic to establish care. He was recently diagnosed with paroxysmal atrial fibrillation and was started on apixaban for stroke prophylaxis. Due to highly symptomatic palpitations despite maximum tolerated beta-blocker therapy, the decision is made today to initiate oral amiodarone for rhythm control. He has a history of essential hypertension but no other major medical conditions. Which of the following tests are indicated for baseline and routine ongoing monitoring of this new antiarrhythmic therapy? (Select all that apply)

A 32-year-old man is brought to the emergency department after a motor vehicle collision. Radiographs reveal a closed, mid-shaft fracture of the right tibia, and the patient is admitted for planned orthopedic fixation. Six hours later, he complains of severe, unrelenting right leg pain that is significantly worse than upon initial presentation. The pain is not relieved by intravenous morphine. On physical examination, the right leg is markedly swollen, tense, and exquisitely tender to palpation. There is severe pain elicited with passive dorsiflexion of the right toes. Distal pulses in the right lower extremity are currently palpable. Which of the following is the most appropriate next step in management?

A 74-year-old woman is brought to the emergency department from a skilled nursing facility due to fever and altered mental status over the past 24 hours. Her medical history includes hypertension, type 2 diabetes mellitus, and osteoarthritis.

Vitals:
Temperature: $39.6^{\circ}\text{C}$ ($103.3^{\circ}\text{F}$)
Blood pressure: $82/52 \text{ mmHg}$
Heart rate: $128/\text{min}$
Respiratory rate: $24/\text{min}$
Oxygen saturation: 94% on room air

Physical examination reveals profound lethargy, scleral icterus, and severe right upper quadrant abdominal tenderness with guarding.

Laboratory studies:
Leukocyte count: $24,500/\text{mm}^3$ (15% bands)
Hemoglobin: $10.2 \text{ g/dL}$
Platelet count: $88,000/\text{mm}^3$
Total bilirubin: $7.8 \text{ mg/dL}$
Direct bilirubin: $6.1 \text{ mg/dL}$
Alkaline phosphatase: $640 \text{ U/L}$
Aspartate aminotransferase: $185 \text{ U/L}$
Alanine aminotransferase: $210 \text{ U/L}$
Prothrombin time: $22 \text{ seconds}$
INR: $2.3$

Right upper quadrant ultrasound demonstrates a dilated common bile duct measuring 1.4 cm with an obstructing echogenic focus. The gallbladder is present but lacks wall thickening or pericholecystic fluid.

Aggressive intravenous fluid resuscitation and broad-spectrum antibiotics are immediately initiated. Following the infusion of 2 liters of crystalloid, her blood pressure is $98/60 \text{ mmHg}$ and her heart rate is $105/\text{min}$.

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

An octogenarian patient with a history of moderate dementia is medically stable for discharge following a prolonged admission for urosepsis. During the hospital course, the patient experienced severe deconditioning and is now unable to perform basic mobility tasks without maximal physical assistance. The primary inpatient team determines that the patient requires transition to a skilled nursing facility (SNF) to receive structured physical therapy and skilled nursing oversight. To ensure a compliant and safe care transition that minimizes readmission risk, arrange the following multidisciplinary and physician actions in the correct chronological sequence.

Match each clinical presentation of a patient experiencing swallowing difficulties or related symptoms with the most appropriate, guideline-indicated next step in the diagnostic workup.

A 56-year-old man is brought to the emergency department by ambulance after vomiting a large amount of bright red blood. He has a history of alcohol use disorder and compensated cirrhosis. On arrival, he is lethargic but localizes to pain and maintains his airway. Blood pressure is 88/55 mm Hg, and pulse is 118/min. Physical examination reveals scleral icterus, palmar erythema, and a distended abdomen with shifting dullness. Two large-bore peripheral intravenous lines are placed, and fluid resuscitation with isotonic crystalloid is initiated. Laboratory studies show:

Which of the following pharmacologic interventions are most appropriate for this patient at this time? (Select all that apply)

A $52$-year-old woman is brought to the emergency department for sudden-onset severe shortness of breath, left-sided chest pain, and lightheadedness. She underwent a right total knee arthroplasty $14$ days ago. On arrival, she is visibly distressed, diaphoretic, and confused.

Vital signs are:
Temperature: $37.1^\circ C$ ($98.8^\circ F$)
Blood pressure: $72/45$ mmHg
Heart rate: $138$/min
Respiratory rate: $34$/min
$SpO_2$: $84\%$ on $15$ L/min via non-rebreather mask

Physical examination reveals pronounced jugular venous distention. Lung auscultation is clear bilaterally. Heart sounds are rapid with a loud $P_2$, but no murmurs are appreciated. The right lower extremity is mildly edematous compared to the left.

Point-of-care echocardiography demonstrates a severely dilated right ventricle with a flattened interventricular septum bowing into the left ventricle, diminished right ventricular free wall motion, and a small, hyperkinetic left ventricle.

Which of the following are the most appropriate initial steps in the stabilization of this patient? (Select 2)

A $55$-year-old man presents for a health maintenance examination. His calculated $10$-year atherosclerotic cardiovascular disease risk is determined to be $12\%$. He has no active symptoms, and his baseline low-density lipoprotein cholesterol is $150\text{ mg/dL}$. Following a shared decision-making discussion, the physician prescribes moderate-intensity atorvastatin for primary prevention. The patient is also counseled on dietary modifications and regular aerobic exercise. Assuming the patient experiences no adverse effects, which of the following is the most appropriate next step in monitoring his therapeutic response?

A 32-year-old woman is brought to the emergency department by paramedics following a high-speed motor vehicle collision. She was the unrestrained driver of a vehicle that struck a concrete barrier. She complains of severe lower abdominal and pelvic pain. Past medical history is unremarkable. Vital signs reveal a temperature of 36.6°C (97.9°F), blood pressure of 72/40 mm Hg, pulse of 138/min, respirations of 26/min, and oxygen saturation of 96% on supplemental oxygen. She is pale, diaphoretic, and restless. Her airway is patent, and breath sounds are present and equal bilaterally. The abdomen is non-distended but tender in the suprapubic region. A pelvic examination demonstrates mechanical instability with anterior-posterior compression. No active external hemorrhage is noted. Two large-bore intravenous lines are established, and a massive transfusion protocol is initiated. Which of the following is the most urgent next step in the stabilization of this patient?

During a routine follow-up visit at the public health clinic, a physician evaluates an asymptomatic patient who recently began treatment for latent tuberculosis infection. Four weeks ago, the patient had a positive interferon-gamma release assay with a normal chest radiograph, leading to the initiation of daily isoniazid and pyridoxine.

The patient currently reports feeling entirely well, specifically denying fatigue, nausea, vomiting, abdominal pain, jaundice, or changes in urine color.

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

An emergency department physician is evaluating a 48-year-old man with a 4-hour history of sudden-onset, right-sided pleuritic chest pain and mild dyspnea. He has a history of severe alcohol use disorder. The patient is currently unhoused and sleeps at a local nighttime-only community shelter. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 128/82 mmHg, heart rate of 88/min, and respiratory rate of 16/min. Oxygen saturation is 97% on room air. Physical examination reveals clear lungs bilaterally and a regular heart rhythm. Laboratory studies demonstrate normal renal and hepatic function, and a high-sensitivity cardiac troponin I level within the normal reference range. Computed tomography pulmonary angiography reveals a small segmental pulmonary embolism in the right lower lobe. Echocardiography shows normal right ventricular size and function. The patient is alert, oriented, and demonstrates a clear understanding of his diagnosis. When discussing the treatment plan, he states, 'Just give me the pills so I can get back to the shelter before I lose my bed for the night.' Which of the following is the most appropriate next step in the disposition and management of this patient?

A 39-year-old woman is evaluated in the emergency department for severe, sudden-onset periumbilical and epigastric pain radiating to her back, which began 4 hours ago. The pain is continuous and associated with severe nausea and nonbilious emesis. Her medical history is significant for morbid obesity, for which she underwent a laparoscopic Roux-en-Y gastric bypass 3 years ago, resulting in a 55-kg (121-lb) weight loss. Her temperature is 37.8°C (100.0°F), blood pressure is 112/72 mmHg, heart rate is 118/min, and respiratory rate is 20/min. Physical examination reveals a non-distended abdomen with severe tenderness out of proportion to palpation, but without marked rebound tenderness or guarding. Laboratory studies show a leukocyte count of 11,500/mm³ and normal serum lipase, bilirubin, and alkaline phosphatase levels. A CT scan of the abdomen and pelvis with intravenous contrast reveals mild mesenteric edema and a cluster of small bowel loops in the left upper quadrant, but no definitive transition point, free air, or target sign is noted by the radiologist. Over the next hour, her pain becomes entirely refractory to intravenous opioids, and her heart rate increases to 134/min. Which of the following is the most appropriate next step in the management of this patient?

A 78-year-old man with end-stage chronic obstructive pulmonary disease (COPD) is evaluated in the outpatient clinic. He requires continuous supplemental oxygen and has had four hospitalizations in the past year for severe acute exacerbations. He is now completely bedbound and states, "I am tired of going to the hospital and being poked with needles. I just want to stay at home and be comfortable for whatever time I have left." His physician estimates his life expectancy to be less than 6 months. The patient is alert, fully oriented, and clearly articulates an understanding of his prognosis and the medical consequences of his decision. Which of the following is the most appropriate next step in management?

A 68-year-old woman with Medicare is evaluated by an orthopedic surgeon on the second post-operative day following an uncomplicated total knee arthroplasty. The surgeon is arranging the patient's discharge and writing an order for post-operative physical therapy. The surgeon holds a 20% equity ownership stake in an independent, comprehensive outpatient rehabilitation facility (CORF) located in the patient's community. The surgeon genuinely believes this specific facility offers the highest quality, most specialized joint rehabilitation in the region. The patient asks the surgeon for a recommendation on where to go for physical therapy. Which of the following is the most appropriate action for the surgeon to take?

A 68-year-old man is admitted to the inpatient palliative care unit due to progressive, severe dyspnea. He has stage IV non-small cell lung cancer with extensive pleural involvement and lymphangitic carcinomatosis. He is currently awake but visibly distressed, breathing at 32 breaths per minute. His oxygen saturation is 89% on room air. The patient has a 'Do Not Resuscitate / Do Not Intubate' (DNR/DNI) order in place, and his stated primary goal of care is maximum comfort.

Arrange the following interventions in the appropriate stepwise order of escalation for the management of this patient's terminal dyspnea, from the initial step to the final step for refractory symptoms.