All practice questions

A 64-year-old man presents with sudden, intractable, generalized abdominal pain that began 2 hours ago. His medical history is significant for coronary artery disease, chronic obstructive pulmonary disease, and daily naproxen use for severe osteoarthritis. Vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 86/52 mmHg, heart rate of 124/min, and respiratory rate of 28/min. Physical examination reveals a rigid, board-like abdomen with severe diffuse tenderness, rebound, and involuntary guarding. An upright chest radiograph demonstrates free air under the right hemidiaphragm. The surgical service is consulted, and an emergent exploratory laparotomy is planned.

Which of the following interventions are essential components of this patient's immediate preoperative management? (Select all that apply)

A 68-year-old man presents to the emergency department complaining of sudden, excruciating pain in his left leg that began 4 hours ago. He has a history of paroxysmal atrial fibrillation and recently stopped taking his prescribed rivaroxaban due to financial constraints. On physical examination, the left lower extremity is notably pale and cool to the touch from the mid-thigh distally. The left femoral pulse is palpable, but the popliteal, dorsalis pedis, and posterior tibial pulses are absent. Handheld continuous-wave Doppler reveals no arterial signals in the left foot, but venous signals remain audible. Neurologic examination of the left lower extremity demonstrates profound loss of sensation extending up to the mid-calf and a new-onset inability to dorsiflex the foot. Intravenous heparin and adequate analgesia are administered immediately. Which of the following is the most appropriate next step in the management of this patient?

A 48-year-old man comes to the clinic for follow-up of treatment-resistant hypertension. His blood pressure remains 168/98 mmHg despite adherence to maximum doses of amlodipine, lisinopril, and hydrochlorothiazide. Laboratory studies two weeks ago showed a serum potassium of 3.1 mEq/L. Subsequent evaluation revealed a plasma aldosterone concentration (PAC) of 34 ng/dL and a suppressed plasma renin activity (PRA) of 0.4 ng/mL/h. A confirmatory intravenous saline infusion test demonstrated persistent elevation of aldosterone levels, confirming the diagnosis of primary aldosteronism. An abdominal computed tomography (CT) scan shows a 1.4-cm, lipid-rich adenoma in the right adrenal gland and a morphologically normal left adrenal gland. The patient is a good surgical candidate and expresses a strong desire for a definitive surgical cure. Which of the following is the most appropriate next step in management?

During an interdisciplinary rounds discussion on the psychiatric ward, the care team plans the discharge of a 35-year-old female who was recently stabilized from an acute manic episode. The patient was successfully transitioned to maintenance lithium carbonate therapy over the past ten days. Her current serum lithium trough level is within the therapeutic window. To appropriately monitor for the most common long-term adverse effects of this pharmacotherapy, which of the following laboratory parameters should be periodically evaluated in the outpatient setting? (Select all that apply)

A 71-year-old man comes to the clinic reporting a 2-month history of worsening mid-to-lower back pain. The pain is constant, does not improve with rest, and occasionally awakens him at night. Over the same period, he has experienced progressive fatigue, constipation, and increased urinary frequency. His past medical history is notable only for mild osteoarthritis, for which he takes acetaminophen as needed. He does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Physical examination reveals tenderness to palpation over the lumbar spine but no focal neurological deficits.

Laboratory results are as follows:

Hemoglobin: $9.2 \text{ g/dL}$
Leukocyte count: $6,500/\mu\text{L}$
Platelet count: $140,000/\mu\text{L}$
Calcium: $11.8 \text{ mg/dL}$
Creatinine: $2.1 \text{ mg/dL}$
Alkaline phosphatase: $95 \text{ U/L}$

Which of the following diagnostic tests should be ordered concurrently as the most appropriate next steps in this patient's initial workup? (Select all that apply)

A 68-year-old man presents to the urgent care clinic with a 4-day history of productive cough, chills, and progressive shortness of breath. His past medical history is significant for hypertension, type 2 diabetes mellitus, and congenital long QT syndrome. Current medications include lisinopril, metformin, and a multivitamin. His temperature is 38.3°C (100.9°F), blood pressure is 134/82 mmHg, pulse is 92/min, and respiratory rate is 22/min. Oxygen saturation is 95% on room air. Pulmonary examination reveals focal crackles and increased tactile fremitus over the left lower lung zone. A chest radiograph demonstrates a left lower lobe consolidation. The patient is diagnosed with community-acquired pneumonia and is deemed stable for outpatient management. Which of the following antimicrobial agents are appropriate to include in his empiric treatment regimen? (Select all that apply)

Match each patient's clinical demographic and risk profile with the most appropriate indicated preventive screening modality.

A 62-year-old man is preparing for hospital discharge following an admission for a severe chronic obstructive pulmonary disease (COPD) exacerbation. During his stay, he required a brief period of noninvasive positive pressure ventilation in the intensive care unit before stabilizing on the general medical ward. His discharge plan includes a new home oxygen requirement and a transition from his previous short-acting bronchodilators to a new combination maintenance inhaler. To ensure a safe transition of care and minimize the risk of readmission, arrange the following discharge planning steps in the most appropriate chronological sequence.

During a routine follow-up evaluation, a primary care physician reviews the laboratory results of a patient who recently began antihypertensive therapy. The patient is a nulliparous female in her mid-fifties with uncomplicated type 2 diabetes mellitus. Three weeks prior, she was prescribed enalapril for blood pressure management. Today, she feels well and denies any dizziness, cough, or peripheral edema. Vital signs demonstrate a blood pressure of $132/84\text{ mmHg}$, compared to a baseline of $154/92\text{ mmHg}$.

Baseline laboratory studies (3 weeks ago):
Serum creatinine: $0.9\text{ mg/dL}$
Serum potassium: $4.2\text{ mEq/L}$

Current laboratory studies:
Serum creatinine: $1.1\text{ mg/dL}$
Serum potassium: $4.6\text{ mEq/L}$

Based on these findings, what is the most appropriate modification to this patient's treatment plan?

Disposition planning is underway in the emergency department for an 82-year-old man who presented with a 3-day history of productive cough, mild shortness of breath, and low-grade fever. He has a history of hypertension, benign prostatic hyperplasia, and severe bilateral knee osteoarthritis. Prior to this illness, he lived alone, ambulated independently with a cane, and managed his own daily activities.

Over the past 48 hours, he has become progressively weaker. He reports two near-falls today and is now unable to bear weight or walk from his bed to the bathroom without two-person assistance. His closest relative lives three hours away.

Vital signs are temperature 37.8°C (100.0°F), blood pressure 135/85 mmHg, pulse 92/min, and respirations 20/min. Pulse oximetry is 95% on room air. He is fully alert and oriented to person, place, and time.

Physical examination reveals crackles in the right lower lung base. Cardiac examination is normal. He has 4/5 motor strength in the lower extremities bilaterally, limited by fatigue, with normal reflexes.

Laboratory studies show:
Blood urea nitrogen: 16 mg/dL
Serum creatinine: 1.0 mg/dL
Leukocyte count: 11,500/mm³

Chest radiography reveals a right lower lobe consolidation.

Based on the patient's objective severity scores and functional capacity, which of the following is the most appropriate disposition?

A 68-year-old man is evaluated in the intensive care unit (ICU) to determine the most appropriate care setting transition. He was admitted 28 days ago for severe community-acquired pneumonia that progressed to acute respiratory distress syndrome. He was intubated on hospital day 2 and underwent tracheostomy placement on day 14. Currently, the patient is hemodynamically stable, has been off vasopressors for two weeks, and is alert and following commands. Renal function and electrolytes are within normal limits. However, he remains dependent on mechanical ventilation. Daily weaning trials have been attempted, but he fatigues after 2 to 3 hours on a trach collar and requires resumption of full ventilatory support. Additionally, he developed a stage 3 sacral pressure ulcer during his acute illness, which currently requires daily sharp debridement and wound vacuum-assisted closure management. Which of the following is the most appropriate disposition for this patient?

A 27-year-old man is brought to the emergency department by his roommate, who found him confused and lethargic next to several empty medication bottles. The patient has a past medical history of major depressive disorder and chronic neuropathic pain. On arrival, he is somnolent but arouses to verbal stimuli. Vital signs are temperature $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure 84/54 mm Hg, pulse 128/min, and respirations 16/min. Pulse oximetry is 97% on room air. Physical examination reveals dry mucous membranes, dilated pupils bilaterally, and warm, flushed skin. Bowel sounds are absent. A 12-lead electrocardiogram demonstrates sinus tachycardia with a QRS interval of 165 ms and a prominent terminal R wave in lead aVR. Which of the following is the most urgent initial step in the stabilization of this patient?

A $68$-year-old man presents to the cardiology clinic for a routine follow-up. He has a history of nonischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$ diagnosed two years ago, as well as chronic kidney disease. He reports experiencing dyspnea when walking approximately one block and requires two pillows to sleep comfortably at night. His current medications include carvedilol $25$ mg twice daily, dapagliflozin $10$ mg daily, and furosemide $80$ mg twice daily.

Vital signs show a blood pressure of $132/82$ mm Hg and a regular heart rate of $64$/min. The estimated jugular venous pressure is $8$ cm H $_2$ O. Lungs are clear to auscultation. Cardiac examination reveals a regular rhythm with a normal S1 and S2, and a prominent S3 gallop. There is trace bilateral pedal edema.

Laboratory studies are as follows:

His estimated glomerular filtration rate is $22$ mL/min/1.73m $^2$. The physician wishes to optimize his heart failure regimen to improve symptoms and reduce mortality. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A $47$-year-old woman with diffuse large B-cell lymphoma is currently undergoing cyclical CHOP chemotherapy. Seven days after her last cycle, she presents to the emergency department with severe chills and a temperature of $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$). Her absolute neutrophil count (ANC) is determined to be $110 \text{ cells/mm}^3$. She has a peripherally inserted central catheter (PICC) in place. Arrange the following diagnostic, monitoring, and therapeutic steps in the most appropriate chronological sequence for the management of this patient's neutropenic fever.

A 28-year-old female is brought to the emergency department triage desk by her sister after collapsing at home. The sister reports that the patient complained of sharp, sudden-onset right lower quadrant abdominal pain shortly before losing consciousness. The patient has no significant past medical history but has not had a menstrual period in seven weeks. On evaluation, the patient is somnolent but groans in response to painful stimuli. She is markedly pale and diaphoretic. Vital signs include a heart rate of 142/min, a blood pressure of 68/36 mmHg, a respiratory rate of 24/min, and an oxygen saturation of 97% on room air. Physical examination reveals a rigid, diffusely tender abdomen with involuntary guarding. Which of the following is the most appropriate immediate next step in the management of this patient?

A 66-year-old man presents to the primary care clinic with a 4-day history of a productive cough, fever, and progressive shortness of breath. His medical history is significant for type 2 diabetes mellitus, hypertension, and major depressive disorder. Current medications include metformin, lisinopril, and citalopram. His temperature is 38.4°C (101.1°F), blood pressure is 132/82 mmHg, pulse is 98/min, and respiratory rate is 22/min. Pulse oximetry shows 94% on room air. Physical examination reveals bronchial breath sounds and crackles over the left lower lung field. Laboratory studies show a leukocyte count of 14,000/mm³ with a left shift. Serum creatinine is 1.1 mg/dL. A chest radiograph demonstrates a left lower lobe consolidation. An electrocardiogram obtained in the clinic reveals a normal sinus rhythm with a QTc interval of 520 msec. Which of the following is the most appropriate outpatient pharmacologic regimen for this patient?

A 55-year-old man with poorly controlled type 2 diabetes mellitus is brought to the emergency department due to a 24-hour history of severe pain and swelling in his right lower leg. He sustained a minor abrasion to his shin three days ago. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is $122/\text{min}$, blood pressure is $88/56\text{ mm Hg}$, and respiratory rate is $22/\text{min}$. Physical examination reveals a markedly swollen, erythematous right lower leg. The erythema is advancing rapidly, and there are violaceous bullae over the anterior shin. Palpation elicits palpable crepitus and pain that is out of proportion to the visual extent of the skin changes. Laboratory studies show:

Aggressive intravenous fluid resuscitation and broad-spectrum antibiotics are immediately initiated. Which of the following is the most appropriate next step in management?

An 82-year-old woman is admitted to the hospital after a mechanical fall at home resulting in a displaced right femoral neck fracture. She is evaluated by the orthopedic surgery team, who recommend urgent hemiarthroplasty to minimize morbidity. Her past medical history is significant for hypertension and atrial fibrillation, for which she takes warfarin. Her vital signs are within normal limits. Laboratory evaluation reveals an International Normalized Ratio (INR) of 3.8. The surgical team wishes to proceed with the operation as soon as it is safe. Which of the following procedural preparation steps are indicated for this patient? (Select all that apply)

An asymptomatic 68-year-old male presents to the primary care office for an annual wellness visit. He has no acute complaints and feels well. His medical history is significant for mild osteoarthritis, which is well controlled with occasional acetaminophen. He is a former smoker who smoked half a pack of cigarettes daily for 20 years, quitting 5 years ago. He drinks alcohol occasionally and exercises three times a week. Review of his records shows a normal screening colonoscopy at age 65 and a normal lipid panel 6 months ago. His blood pressure today is 122/78 mmHg, and his heart rate is 72/min. Physical examination is unremarkable. Which of the following is the most appropriate next step in preventive screening for this patient?

A 42-year-old man is evaluated in the surgical oncology clinic for the management of a recently diagnosed right adrenal mass. He initially presented to his primary care physician with a 6-month history of episodic, severe headaches, profuse sweating, and palpitations. His blood pressure during those episodes was often greater than 190/110 mm Hg. Subsequent biochemical testing revealed markedly elevated 24-hour urine fractionated metanephrines and catecholamines. A CT scan of the abdomen without contrast demonstrated a 5.5-cm, lipid-poor, right adrenal mass. The patient is scheduled to undergo a laparoscopic right adrenalectomy. His current blood pressure is 178/104 mm Hg and his heart rate is 102/min.

Arrange the following procedural and management steps in the most appropriate chronological order to safely prepare for and perform the surgical intervention.