All practice questions

A 54-year-old woman is brought to the emergency department via ambulance after the sudden onset of severe, tearing chest pain that radiates to her interscapular region. Her medical history is significant for severe persistent asthma, for which she takes an inhaled corticosteroid and long-acting beta-agonist, and hypertension, for which she takes amlodipine. On arrival, she appears in acute distress. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $215/115\text{ mmHg}$ in the right arm and $185/95\text{ mmHg}$ in the left arm, heart rate is $118\text{/min}$, and respiratory rate is $24\text{/min}$. Pulse oximetry shows $94\%$ on room air. Physical examination reveals a diaphoretic woman. Pulmonary auscultation reveals diffuse bilateral expiratory wheezing. Cardiovascular examination shows a regular tachycardic rhythm with no murmurs, rubs, or gallops. Radial pulses are symmetric, but the left femoral pulse is diminished. CT angiography of the chest confirms a Stanford type B aortic dissection. Which of the following is the most appropriate initial pharmacologic intervention for this patient?

While rounding in the medical intensive care unit, a physician evaluates the laboratory profile of a 62-year-old woman being treated for septic shock secondary to a urinary tract infection. The patient has a 10-year history of focal impaired awareness seizures and takes oral phenytoin $300$ mg daily. Currently, she is mechanically ventilated, receiving a continuous norepinephrine infusion, and deeply sedated. The nursing staff reports no abnormal movements or clinical seizure activity over the past $48$ hours.

Laboratory results from this morning are compared to her admission baseline:

Which of the following is the most appropriate next step regarding the patient's antiseizure therapy?

A 65-year-old man is evaluated in the intensive care unit. He was admitted 12 days ago for status epilepticus and subsequently developed ventilator-associated pneumonia. He was intubated and received continuous enteral nutrition via a nasogastric tube. His seizures have been well controlled on enteral phenytoin suspension, requiring a high dose of 400 mg every 8 hours to maintain a therapeutic total serum trough level of 16 mcg/mL. His pneumonia is being treated with intravenous meropenem.

Today, the patient's respiratory status has significantly improved, and he is extubated. The continuous enteral feeds are discontinued, and he successfully passes a swallowing evaluation. He is advanced to a standard oral diet and is scheduled to transition to oral phenytoin capsules. His serum albumin is 3.5 g/dL. Renal and hepatic functions are within normal limits.

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

A 58-year-old male is brought to the emergency department by his spouse due to sudden-onset neurological deficits. Approximately 45 minutes prior to arrival, he abruptly developed difficulty speaking and right-sided weakness while eating dinner. His medical history is significant for essential hypertension and hyperlipidemia, for which he takes amlodipine and atorvastatin. He has no history of bleeding disorders and does not take any anticoagulant medications. Vital signs show a blood pressure of 175/95 mmHg, heart rate of 82/min, and respiratory rate of 16/min. Neurologic examination reveals expressive aphasia, a right-sided facial droop, and 2/5 muscle strength in the right upper and lower extremities. The clinical team is evaluating the patient for acute reperfusion therapy with intravenous alteplase. Which of the following diagnostic studies MUST be obtained and their results reviewed prior to the administration of this therapy? (Select all that apply)

A 62-year-old woman comes to the outpatient clinic reporting a 2-day history of dysuria and increased urinary frequency. She denies fever, chills, flank pain, nausea, or vomiting. Her medical history is significant for hypertension and a mechanical mitral valve replacement performed 4 years ago, for which she is on chronic anticoagulation. Current medications include warfarin, lisinopril, and metoprolol. Her temperature is 37.1°C (98.8°F), blood pressure is 128/82 mm Hg, and pulse is 76/min. Physical examination reveals mild suprapubic tenderness to palpation but no costovertebral angle tenderness.

Laboratory studies show:

Which of the following is the most appropriate pharmacologic intervention?

A $26$-year-old woman with a history of type 1 diabetes mellitus presents to the emergency department complaining of diffuse abdominal pain, nausea, and persistent vomiting over the past $24$ hours. She recently had a urinary tract infection and missed her last two subcutaneous insulin doses. Vital signs reveal a blood pressure of $90/60 \text{ mm Hg}$, a heart rate of $122 \text{/min}$, and a respiratory rate of $28 \text{/min}$ with deep, rapid breathing. Point-of-care testing shows a blood glucose level of $580 \text{ mg/dL}$. Arterial blood gas analysis demonstrates a pH of $7.12$ and a serum bicarbonate of $10 \text{ mEq/L}$. Urinalysis is strongly positive for ketones. Arrange the following therapeutic and monitoring interventions in the most appropriate chronological sequence for managing this patient's condition.

A resident physician is preparing to place a right internal jugular central venous catheter in a patient requiring vasopressor support for septic shock. The necessary equipment has been brought to the patient's bedside. Arrange the following steps of the central venous catheterization procedure in the correct chronological order.

A 42-year-old woman is evaluated in the clinic due to an 8-month history of progressively worsening shortness of breath. She initially noticed dyspnea only when climbing stairs, but now experiences it while walking on level ground. She has no significant past medical history, takes no medications, and has never smoked. Vital signs show blood pressure of 118/76 mm Hg, heart rate of 88/min, respiratory rate of 18/min, and oxygen saturation of 96% on room air. Jugular venous pulsation is visible 8 cm above the sternal angle. Chest auscultation reveals clear breath sounds bilaterally. Cardiac examination shows a parasternal heave, a loud pulmonic component of the second heart sound (P $_2$), and a faint holosystolic murmur at the lower left sternal border that augments with inspiration. There is trace lower extremity edema. Initial diagnostic testing reveals the following:

- ECG: Right axis deviation and right ventricular hypertrophy.
- Chest X-ray: Enlarged central pulmonary arteries with clear lung parenchyma.
- Transthoracic echocardiogram: Right ventricular dilation with an estimated right ventricular systolic pressure of 65 mm Hg. Left ventricular size and systolic function are normal. There is no significant mitral or aortic valvular disease.
- Pulmonary function tests: Normal spirometry and lung volumes.
- High-resolution chest CT: No evidence of interstitial lung disease.

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

A 29-year-old man is brought to the emergency department after a high-speed motorcycle collision. He was ejected from the vehicle and found 30 feet away. On arrival, his airway is patent. He is confused and diaphoretic. Temperature is 36.2 C (97.2 F), pulse is 135/min, blood pressure is 85/50 mmHg, and respirations are 28/min. Primary survey reveals a rigid, distended abdomen and a grossly deformed right femur. A portable chest radiograph demonstrates a widened mediastinum with loss of the aortic knob contour. A focused assessment with sonography for trauma (FAST) is positive for free fluid in the hepatorenal and splenorenal recesses. The patient receives a rapid infusion of 2 units of uncrossmatched packed red blood cells, which improves his blood pressure to 105/65 mmHg. A CT scan of the chest, abdomen, and pelvis with intravenous contrast reveals a Grade III blunt thoracic aortic injury (pseudoaneurysm) just distal to the left subclavian artery, and a Grade IV splenic laceration with active contrast extravasation. While transferring the patient from the CT scanner to the stretcher, his blood pressure precipitously drops to 65/40 mmHg and his pulse increases to 150/min. He becomes unresponsive and is immediately endotracheally intubated. Which of the following is the most appropriate next step in the surgical management of this patient?

Paramedics transport a 24-year-old male to the emergency room after he collapsed at an outdoor food festival. Bystanders witnessed him rapidly develop severe respiratory distress and facial swelling shortly after consuming a dessert. Upon arrival, the patient is profoundly agitated, diaphoretic, and grasping his neck. Vital signs include a blood pressure of 76/42 mm Hg, a heart rate of 134/min, and a respiratory rate of 28/min. Pulse oximetry indicates an oxygen saturation of 88% on room air. Clinical evaluation demonstrates marked edema of the tongue and lips, a widespread erythematous urticarial rash across the torso, and prominent inspiratory stridor with minimal bilateral air movement. Which of the following is the most appropriate initial step in the stabilization of this patient?

Paramedics transport a 24-year-old man to the emergency department after he dove headfirst into a shallow lake. Bystanders successfully pulled him from the water.

Upon arrival, the patient is awake, alert, and speaking clearly. He reports a complete inability to move his arms or legs. His breathing pattern is shallow and entirely diaphragmatic.

Vital signs are as follows:
Temperature: 36.0°C (96.8°F)
Blood pressure: 72/42 mm Hg
Heart rate: 48/min
Respiratory rate: 26/min
Oxygen saturation: 92% on room air

Physical examination reveals flaccid paralysis with 0/5 motor strength in all four extremities. Sensation to pain and temperature is absent below the clavicles. His skin is warm and flushed throughout all extremities.

Based on trauma and shock management principles, arrange the following acute resuscitation steps in the correct prioritized sequence from first to last.

A 61-year-old man with a history of poorly controlled type 2 diabetes mellitus and chronic kidney disease stage 3b (baseline estimated glomerular filtration rate of $42 \text{ mL/min/1.73 m}^2$) presents to the emergency department with severe, progressively worsening mid-back pain for the past 10 days. He reports that the pain now radiates in a band-like pattern around his lower chest. Over the past 12 hours, he has experienced progressive weakness in both legs and notes he has not urinated since the previous evening.

Vital signs:
Temperature: $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$)
Blood pressure: $148/92 \text{ mmHg}$
Heart rate: $102 \text{ /min}$
Respiratory rate: $16 \text{ /min}$

Neurologic examination reveals 3/5 strength in hip flexion and knee extension bilaterally, absent patellar reflexes, and diminished pinprick sensation below the T10 dermatome. Bedside ultrasound reveals a post-void residual bladder volume of $650 \text{ mL}$. The patient is promptly catheterized.

Given the high clinical suspicion for a critical neurological emergency, which of the following diagnostic studies should be ordered concurrently as the most appropriate initial evaluation? (Select exactly 3)

A 45-year-old woman presents to the primary care clinic for follow-up of elevated blood pressure. Over her last three visits, her blood pressure has averaged 152/94 mmHg, and a diagnosis of primary hypertension is established. Her medical history is notable for bipolar I disorder, which has been well controlled on a stable dose of lithium for the past four years. Her recent serum lithium level was within the target therapeutic range, and her comprehensive metabolic panel shows normal renal function. The physician decides to initiate pharmacologic therapy for her hypertension. Which of the following antihypertensive medications is most likely to decrease the patient's renal clearance of lithium and precipitate drug toxicity?

Match each patient's clinical presentation and calculated risk stratification score to the most appropriate initial disposition setting.

A 61-year-old man with a history of alcohol use disorder and decompensated cirrhosis is evaluated on the medical ward for increasing confusion and decreased urine output. He was admitted two days ago for management of large-volume ascites. Over the past 24 hours, he has become progressively lethargic.

Vital signs show a temperature of 38.1°C (100.6°F), blood pressure of 84/52 mmHg, heart rate of 110/min, and respiratory rate of 18/min. Physical examination reveals scleral icterus, spider angiomas, and shifting dullness. He is oriented to name only and exhibits a positive asterixis.

Laboratory studies are as follows:

A diagnostic paracentesis yields cloudy fluid with an absolute neutrophil count of 650/mm³. Urinalysis shows no casts or red blood cells. A 1.5 L intravenous normal saline bolus was administered over the last 12 hours without any improvement in his blood pressure or serum creatinine.

Which of the following pharmacologic interventions are indicated in the management of this patient? (Select all that apply.)

A 68-year-old woman is evaluated for hospital discharge. She was admitted 5 days ago for severe gastroenteritis complicated by acute kidney injury. Her diarrhea has resolved, and she is tolerating a regular diet. Vital signs are normal. Laboratory studies show a blood urea nitrogen of $24 \text{ mg/dL}$ and serum creatinine of $1.1 \text{ mg/dL}$ (baseline creatinine from one month ago was $1.0 \text{ mg/dL}$). Prior to admission, she lived independently in a single-level apartment and required no assistance with activities of daily living. Today, physical therapy evaluates her and notes significant generalized deconditioning from prolonged bed rest. She now requires moderate physical assistance to transfer from the bed to a chair and to ambulate short distances. The physical therapist recommends short-term daily rehabilitative therapy but notes that the patient fatigues rapidly, tolerating a maximum of 45 minutes of physical activity per day. Which of the following is the most appropriate disposition for this patient?

A 48-year-old man is hospitalized with severe acute gallstone pancreatitis. On hospital day 21, he develops a fever of 39.2°C (102.6°F), leukocytosis of 22,000/mm³, and worsening diffuse abdominal pain. A contrast-enhanced CT scan of the abdomen shows a 12-cm region of walled-off pancreatic necrosis containing multiple gas bubbles. Assuming the patient continues to exhibit signs of systemic toxicity and fails to clinically improve after each successive therapeutic intervention, arrange the following management steps in the correct chronological sequence according to the evidence-based 'step-up' approach for infected necrotizing pancreatitis.

An ambulance brings a 68-year-old man to the acute care bay following the abrupt onset of excruciating, diffuse abdominal pain that began 4 hours prior. He has a known medical history of paroxysmal atrial fibrillation and hypertension but recently discontinued his prescribed oral anticoagulation due to financial constraints. On arrival, his vital signs demonstrate a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), a heart rate of $130/\text{min}$ with an irregularly irregular rhythm, a blood pressure of $82/48\text{ mmHg}$, and a respiratory rate of $24/\text{min}$. Physical examination reveals a rigid, markedly distended abdomen with severe diffuse tenderness, absent bowel sounds, and pronounced involuntary guarding. Point-of-care laboratory testing reveals a leukocyte count of $22,000/\text{mm}^3$ and a serum lactate level of $8.1\text{ mmol/L}$. After initiating aggressive intravenous fluid resuscitation and broad-spectrum antibiotics, which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man comes to the primary care clinic reporting a 9-month history of excessive sweating, fatigue, and bilateral knee pain. He also mentions that his wedding ring no longer fits and he recently had to purchase shoes that are a size larger than his previous footwear. His wife reports that his snoring has worsened significantly over the past year. Vital signs are within normal limits. Physical examination reveals a prominent supraorbital ridge, an enlarged tongue, and broad, doughy hands. Given the high clinical suspicion for a specific endocrine disorder, a serum insulin-like growth factor-1 (IGF-1) level is ordered and returns significantly elevated for his age and sex. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 22-year-old man is brought to the emergency department by emergency medical services after a high-speed motor vehicle collision. He is in severe respiratory distress and is unable to speak in full sentences. His blood pressure is 80/40 mm Hg, pulse is 135/min, and respirations are 36/min. Oxygen saturation is 84% on room air. Physical examination reveals distended neck veins, absent breath sounds over the right hemithorax, and tracheal deviation to the left side. Which of the following is the most appropriate next step in management?