All practice questions

A 58-year-old male arrives at the emergency department reporting severe, crushing substernal chest pain accompanied by profuse sweating that began one hour ago. On physical examination, he is pale and visibly uncomfortable. Jugular venous distention is prominently noted, but auscultation of the lungs reveals clear breath sounds bilaterally without crackles. Vital signs demonstrate a blood pressure of 78/50 mm Hg, a heart rate of 54/min, a respiratory rate of 16/min, and an oxygen saturation of 97% on room air. An electrocardiogram obtained at triage displays prominent ST-segment elevations in leads II, III, and aVF. Intravenous access is rapidly secured. What is the most appropriate initial step in the stabilization of this patient?

A 24-year-old man presents to the ambulatory care clinic with a painful swelling on his left thigh that has been enlarging over the past 4 days. He has no significant past medical history and takes no medications. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $118/76 \text{ mm Hg}$, pulse is $74/\text{min}$, and respiratory rate is $14/\text{min}$. Physical examination reveals a 3-cm, markedly tender, erythematous, and fluctuant nodule on the anterior left thigh. There is no surrounding induration or purulent drainage, and the patient reports no systemic symptoms such as chills or body aches. Which of the following is the most appropriate next step in management?

A 64-year-old woman is hospitalized for a massive unprovoked pulmonary embolism. She is initially managed with a continuous intravenous unfractionated heparin infusion. Six days after admission, routine laboratory monitoring reveals a platelet count of $115,000/\mu L$, a significant decline from her admission baseline of $280,000/\mu L$. Concurrently, she reports new-onset right calf pain, and Doppler ultrasonography confirms a new right lower extremity deep venous thrombosis.

Heparin-induced thrombocytopenia (HIT) is suspected. Heparin is immediately discontinued, and a continuous intravenous infusion of argatroban is started. A serotonin release assay subsequently returns positive, confirming the diagnosis of HIT.

Over the next 72 hours, the patient's platelet count steadily recovers to $190,000/\mu L$. The care team decides to transition her to oral warfarin for long-term anticoagulation. Warfarin is initiated at $5 \text{ mg}$ daily while the argatroban infusion is maintained.

Today is the fourth day of combined argatroban and warfarin therapy. The patient is hemodynamically stable without any signs of clinical bleeding. Morning laboratory studies reveal the following:

* Platelet count: $230,000/\mu L$
* Activated partial thromboplastin time (aPTT): $62 \text{ seconds}$ (target therapeutic range: $45$-$75 \text{ seconds}$)
* Prothrombin time (PT): $36 \text{ seconds}$
* International Normalized Ratio (INR): $3.1$

Which of the following is the most appropriate next step in the monitoring and treatment evaluation of this patient's anticoagulation?

An established patient in the gastroenterology clinic, a 29-year-old male, presents for his annual follow-up. He was diagnosed with pancolitis (ulcerative colitis) six years ago, which has remained in deep remission on maintenance mesalamine therapy. Today, he reports feeling well overall but mentions new-onset generalized pruritus that is worse at night. Vital signs are within normal limits. Physical examination reveals mild excoriations on his extremities but no jaundice, scleral icterus, or hepatosplenomegaly.

Routine laboratory evaluation demonstrates:
Aspartate aminotransferase (AST): 38 U/L
Alanine aminotransferase (ALT): 42 U/L
Alkaline phosphatase: 410 U/L
Total bilirubin: 0.9 mg/dL

Arrange the following diagnostic investigations in the most appropriate sequential order for evaluating this patient's suspected condition, starting with the immediate next step for undifferentiated cholestasis and progressing to the most definitive test for variant disease.

A 68-year-old man is evaluated in the intensive care unit for a new-onset fever and increasing vasopressor requirements. He was admitted 12 days ago for severe acute respiratory distress syndrome secondary to viral pneumonia. He remains mechanically ventilated. Current medications include continuous infusions of propofol, fentanyl, and norepinephrine, as well as prophylactic enoxaparin. Temperature is 39.2°C (102.6°F), blood pressure is 88/54 mm Hg, pulse is 118/min, and respiratory rate is 24/min on the ventilator. Physical examination reveals right upper quadrant rigidity and guarding when sedation is temporarily lightened. Laboratory studies show a leukocyte count of 22,000/mm³ with a left shift. Liver function tests reveal a normal total bilirubin and alkaline phosphatase, but mildly elevated aspartate and alanine aminotransferases. A bedside right upper quadrant ultrasound demonstrates a distended gallbladder with a wall thickness of 6 mm, significant pericholecystic fluid, and no visible gallstones or biliary ductal dilation. Which of the following is the most appropriate next step in management?

A 67-year-old man presents to the clinic with excruciating pain, redness, and swelling in his right great toe that started abruptly yesterday. The pain is severe enough that he cannot tolerate the touch of a bedsheet or wear a regular shoe. His past medical history is significant for type 2 diabetes mellitus, hypertension, coronary artery disease, and stage 4 chronic kidney disease. His most recent laboratory studies from two weeks ago showed a serum creatinine of 3.2 mg/dL and an estimated glomerular filtration rate (eGFR) of 20 mL/min/1.73 m². Vital signs are temperature 37.1°C (98.8°F), blood pressure 152/90 mm Hg, and heart rate 88/min. Physical examination reveals an erythematous, warm, and exquisitely tender right first metatarsophalangeal joint. The clinical picture is highly consistent with an acute gout flare. Which of the following is the most appropriate pharmacologic intervention for this patient?

During a clinic visit, a physician evaluates a 68-year-old man who complains of severe right foot pain that frequently awakens him from sleep. The patient notes that hanging his foot over the edge of the mattress partially alleviates the discomfort. His medical history is significant for long-standing type 2 diabetes mellitus complicated by peripheral neuropathy, hypertension, and stage 3 chronic kidney disease. Vital signs are within normal limits. Physical examination reveals a 1.5-cm dry, blackened eschar on the distal tip of the right great toe with minimal surrounding erythema. The right foot feels cool to the touch, and both the dorsalis pedis and posterior tibial pulses are nonpalpable. The physician performs an in-office ankle-brachial index (ABI) measurement to evaluate for peripheral arterial disease. The right ABI is calculated to be 1.45. Which of the following is the most appropriate next step in the diagnostic workup?

During morning rounds in the cardiac intensive care unit, the medical team reviews the chart of a 61-year-old female who was admitted five days ago for an acute anterior myocardial infarction complicated by a left ventricular mural thrombus. She has been receiving a continuous intravenous infusion of unfractionated heparin since admission. Her daily laboratory results show a platelet count of $88,000/\text{mm}^3$, a precipitous decline from her baseline of $245,000/\text{mm}^3$ upon admission. On physical examination, she reports new-onset right lower extremity pain, and subsequent compression ultrasonography reveals an acute deep vein thrombosis in the right popliteal vein. Suspecting heparin-induced thrombocytopenia (HIT), the attending physician immediately discontinues the heparin infusion and initiates a continuous infusion of argatroban. The team discusses the long-term plan to discharge the patient on oral warfarin therapy.

Which of the following is the most appropriate protocol for monitoring this patient's recovery and transitioning her to the planned oral anticoagulant?

Match each patient presenting with chest pain to the most appropriate next step in diagnostic test sequencing, based on their individual risk factors and comorbidities.

A 48-year-old man is evaluated in the hospital for a 3-day history of fever, pleuritic chest pain, and hemoptysis. He underwent a deceased-donor renal transplant 4 months ago for end-stage renal disease secondary to IgA nephropathy. His current medications include tacrolimus, mycophenolate mofetil, and prednisone. Temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, pulse is $98/\text{min}$, and respiratory rate is $18/\text{min}$. Laboratory studies show a serum creatinine of $1.4\text{ mg/dL}$. A CT scan of the chest demonstrates a right upper lobe cavitary lesion with a surrounding halo of ground-glass opacity. Serum galactomannan assay is prominently elevated. The attending physician plans to initiate the first-line targeted antimicrobial therapy for this patient's opportunistic infection. Which of the following is the most appropriate concurrent pharmacologic management step?

A $62$-year-old man is evaluated on the medical ward for new-onset right calf swelling and pain. He was admitted $6$ days ago for severe community-acquired pneumonia and was started on intravenous antibiotics and subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $128/82\text{ mmHg}$, pulse $88/\text{min}$, and respirations $16/\text{min}$. Physical examination reveals a swollen, erythematous, and tender right calf. A lower extremity venous duplex ultrasound confirms a proximal deep vein thrombosis in the right popliteal vein. Laboratory studies from today are compared to admission values:

Which of the following is the most appropriate pharmacologic intervention for this patient?

A 72-year-old man comes to the clinic for a routine follow-up. He has a history of a mechanical aortic valve replacement performed 4 years ago. He is maintained on a stable daily dose of warfarin, and his international normalized ratio (INR) has consistently remained within the target therapeutic range of 2.5 to 3.5 for the past year. Two weeks ago, the patient was diagnosed with highly symptomatic paroxysmal atrial fibrillation and was started on amiodarone by his cardiologist. He reports no bleeding, bruising, dizziness, or palpitations today. His vital signs are within normal limits, and physical examination is unremarkable. Which of the following is the most appropriate next step in the monitoring and management of this patient's pharmacotherapy?

An adult patient is undergoing treatment in the intensive care unit for diabetic ketoacidosis. Initial therapy with a continuous intravenous insulin infusion and fluid resuscitation has been established. Arrange the following monitoring, treatment adjustment, and de-escalation steps in the standard chronological sequence required to safely resolve the episode and transition the patient to a subcutaneous maintenance regimen.

A 28-year-old woman is evaluated in the emergency department for a 2-day history of right-sided back pain, fever, and chills. She also reports severe nausea and has vomited four times over the past 6 hours. She has no significant past medical history and takes no daily medications.

Temperature is 39.0°C (102.2°F), blood pressure is 115/75 mmHg, pulse is 112/min, and respirations are 18/min. Physical examination reveals marked right-sided costovertebral angle tenderness. The patient appears flushed and actively vomits a small amount of bilious fluid during the examination.

Laboratory results:
Leukocyte count: 16,500/mm³
Serum creatinine: 0.8 mg/dL
Urine pregnancy test: Negative
Urinalysis: Positive for nitrites and leukocyte esterase; >50 WBCs/hpf

The patient is given 1 L of intravenous normal saline, intravenous ceftriaxone, and intravenous ondansetron. Two hours later, her temperature is 38.3°C (100.9°F), pulse is 95/min, and blood pressure is 118/78 mmHg. The nurse provides her with a small cup of water, which she immediately vomits.

Based on these findings, which of the following is the most appropriate disposition for this patient?

A 71-year-old woman is transported from a skilled nursing facility to the emergency department due to a sudden decline in responsiveness over the past six hours. The accompanying documentation notes that she had foul-smelling urine earlier in the shift. Her past medical history includes advanced vascular dementia and type 2 diabetes mellitus. On presentation, she is lethargic, muttering incomprehensibly, and opens her eyes only to painful stimuli. Vital signs reveal a blood pressure of $72/40 \text{ mm Hg}$, a heart rate of $134/\text{min}$, a respiratory rate of $26/\text{min}$, and a core temperature of $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$). Oxygen saturation is $95\%$ on ambient air. Physical examination demonstrates warm, flushed extremities with bounding peripheral pulses. A chronic indwelling urinary catheter is in place, draining turbid, dark fluid. Which of the following interventions should be ordered SIMULTANEOUSLY as the most appropriate initial steps in management? (Select all that apply)

A 31-year-old woman is brought to the emergency department after sustaining a stab wound to the left lower chest. On arrival, she is pale, diaphoretic, and confused. Her blood pressure is 72/40 mm Hg, pulse is 142/min, and respirations are 32/min. Oxygen saturation is 92% on 15 L/min of oxygen via a non-rebreather mask. Primary survey reveals a 3-cm penetrating wound in the left sixth intercostal space at the midaxillary line. Breath sounds are markedly decreased on the left. The trachea is midline, and the jugular veins are flat. Bedside extended focused assessment with sonography for trauma (eFAST) reveals a large accumulation of fluid in the left hemithorax, with no pericardial effusion or free intraperitoneal fluid. Two large-bore peripheral intravenous lines are established.

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

A 48-year-old woman is evaluated in the intensive care unit for progressive confusion, right upper quadrant abdominal pain, and high fever over the past 24 hours. Her medical history is significant for a Roux-en-Y gastric bypass performed 3 years ago for severe obesity, and an uncomplicated laparoscopic cholecystectomy 10 years ago. She has no known allergies. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $82/50 \text{ mm Hg}$ despite the rapid administration of 3 L of intravenous crystalloid solution, heart rate is 128/min, and respiratory rate is 24/min. She has been started on a norepinephrine infusion. Physical examination reveals scleral icterus and marked tenderness in the right upper quadrant without rebound or guarding. She is lethargic and oriented only to person. Laboratory studies show:

- Leukocyte count: $22,000/\text{mm}^3$ (85% neutrophils, 10% bands)
- Platelet count: $95,000/\text{mm}^3$
- Total bilirubin: $8.4 \text{ mg/dL}$
- Direct bilirubin: $6.2 \text{ mg/dL}$
- Alkaline phosphatase: $520 \text{ U/L}$
- Aspartate aminotransferase (AST): $145 \text{ U/L}$
- Alanine aminotransferase (ALT): $130 \text{ U/L}$
- International normalized ratio (INR): $1.6$

A right upper quadrant ultrasound reveals a dilated common bile duct measuring 14 mm with internal echogenic debris and a suspected calculus in the distal aspect. The patient is receiving empiric intravenous broad-spectrum antibiotics. Which of the following is the most appropriate next step in the procedural management of this patient?

A 45-year-old woman is admitted to the intensive care unit with septic shock requiring vasopressor support. The physician prepares to place a right internal jugular central venous catheter using the Seldinger technique. After proper sterile preparation, draping, and administration of local anesthesia, arrange the following steps in the correct chronological sequence for inserting the catheter.

Evaluate the following hospitalized patients who are nearing medical stability on the acute care service. Match each patient's clinical presentation and functional status with the most appropriate post-acute care disposition setting.

A 68-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) presents to the emergency department with a two-day history of progressively worsening shortness of breath, increased cough frequency, and a change in sputum from clear to thick, yellow-green. Vital signs show a temperature of 37.6°C (99.7°F), blood pressure of 138/86 mmHg, heart rate of 112/min, and respiratory rate of 26/min. Pulse oximetry is 88% on room air. Pulmonary examination reveals diffuse expiratory wheezing with a prolonged expiratory phase. Electrocardiogram shows sinus tachycardia. In addition to providing supplemental oxygen to maintain saturation between 88% and 92%, which of the following pharmacologic interventions are indicated for the initial management of this patient's acute exacerbation? (Select 3)