A
B
C
D
100
A 58-year-old man hospitalized 5 days ago for a COPD exacerbation is now evaluated for discharge. He required bilevel positive airway pressure for 1 day because of acute hypercapnic and hypoxic respiratory failure. He was treated with prednisone and levofloxacin. This is his second hospitalization for a COPD exacerbation in the past 6 months and the fourth course of prednisone for his COPD in that time. Before hospitalization, his baseline function was limiting dyspnea after walking a few minutes. Medications are inhaled fluticasone furoate-umeclidinium-vilanterol.
On physical examination, oxygen saturation is 96% with the patient breathing ambient air. BMI is 29. He coughs frequently during examination, and faint expiratory wheezing is present in the upper lobes of the lungs. Cardiac examination is normal.
Arterial blood gas studies (at time of discharge):
pH
7.39
PCO2
43 mm Hg (5.7 kPa)
PO2
75 mm Hg (10.0 kPa)
Prehospitalization spirometry showed a postbronchodilator reduced FEV1/FVC ratio and an FEV1 of 42% of predicted.
Inhaler technique is reviewed. He is enrolled in a supervised pulmonary rehabilitation program. Immunizations are up to date.
Which of the following is the most appropriate additional treatment?
Roflumilast
Nocturnal noninvasive bilevel positive airway pressure ventilation
Supplemental oxygen
No additional treatment
100
A 29-year-old man is evaluated in the emergency department after transport by emergency medical services. He was found sitting on his garage floor, lethargic, with an empty container of automotive coolant nearby.
On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 108/58 mm Hg, pulse rate is 118/min, respiration rate is 26/min, and oxygen saturation is 99% with the patient breathing ambient air. He arouses briefly to loud voice but is not interactive.
Laboratory studies:
Creatinine
1.3 mg/dL (114.9 μmol/L)
Glucose
Normal
Sodium
138 mEq/L (138 mmol/L)
Potassium
4.8 mEq/L (4.8 mmol/L)
Chloride
104 mEq/L (104 mmol/L)
Bicarbonate
12 mEq/L (12 mmol/L)
Lactate
Normal
Calculated osmolal gap
Elevated
Arterial blood gas studies:
pH
7.25
PCO2
28 mm Hg (3.7 kPa)
PO2
98 mm Hg (13.0 kPa)
Which of the following is the most appropriate treatment?
Fomepizole and hemodialysis
Ethanol
Fomepizole
Lorazepam
100
A 25-year-old man is seen in follow-up examination for asthma diagnosed 2 months ago. He reports that his symptoms are now well controlled without use of his rescue inhaler, and results of the Asthma Control Test confirm well-controlled asthma. During the visit, he describes feeling down on many days, with difficulty falling asleep and early morning awakening. Depression screening with the Patient Health Questionnaire-2 is positive. Medications are beclomethasone, montelukast, and albuterol.
On physical examination, vital signs and pulmonary examination are normal.
Which of the following is the most appropriate treatment?
Stop montelukast
Begin escitalopram
Begin salmeterol
Stop beclomethasone; begin budesonide-formoterol
100
A 72-year-old man is evaluated for daytime sleepiness. His wife notes that he snores. He sleeps 8 hours each night. On most days of the week, he feels sleepy and will nap for 45 minutes. Medical history is significant for atrial fibrillation and heart failure. Medications are valsartan-sacubitril, metoprolol, furosemide, spironolactone, empagliflozin, and apixaban.
On physical examination, vital signs are normal. BMI is 27. Low-lying soft palate, irregularly irregular cardiac rhythm, normal central venous pressure, clear lung fields, and chronic venous stasis are present.
Transthoracic echocardiogram obtained 1 year ago showed left ventricular enlargement and left ventricular ejection fraction of 40%.
Which of the following is the most appropriate test?
Polysomnography
Actigraphy
Home sleep apnea testing
Overnight oximetry
200
A 55-year-old man is evaluated for a 2-month history of shoulder pain and progressive weakness in his right hand. The pain radiates to his scapula. He has no shortness of breath or cough. He has a 30-pack-year smoking history and quit smoking 15 years ago. His only medication is ibuprofen for pain.
On physical examination, vital signs are normal. Ptosis and miosis of the right eye are observed. He has mild atrophy of the right hand muscles and decreased grip strength in his right hand. Lungs are clear to auscultation.
Complete blood count and metabolic profile are normal.
Chest radiograph is shown.
Which of the following is the most appropriate next step in management?
CT of chest
Bronchoscopy with biopsy
CT-guided biopsy
Referral for surgical resection
200
A 45-year-old woman is evaluated in the emergency department 2 days after elective laparoscopic cholecystectomy. She is febrile, has emesis, and reports abdominal pain and fullness.
On physical examination, temperature is 38.4 °C (101.1 °F), blood pressure is 110/50 mm Hg, pulse rate is 115/min, respiration rate is 28/min, and oxygen saturation is 94% with the patient breathing ambient air. Abdominal examination reveals right-upper-quadrant tenderness and diminished and infrequent bowel sounds. There are decreased breath sounds in the right lung base. The patient is confused. Laparoscopy wounds are intact, with no drainage or erythema.
Which of the following is the best venue of care for this patient?
ICU
Emergency department observation unit
General medical ward
Outpatient
200
A 29-year-old man is evaluated in the hospital for hemorrhagic shock. He has osteogenesis imperfecta and was admitted for a right hip fracture repair 2 days ago. He was placed on low-molecular-weight heparin postoperatively.
Blood pressure is 84/44 mm Hg, pulse rate is 132/min, and respiration rate is 31/min. Oxygen saturation is 91% using a nonrebreather mask. Cardiac examination reveals tachycardia but no murmurs or gallops. He has copious amounts of blood coming from his nose, and there is swelling, bruising, and oozing at the surgical site.
He has an 18-gauge peripheral intravenous catheter in his left forearm.
Which of the following is the most appropriate form of additional intravenous access in this patient?
18-Gauge peripheral catheter in the right arm
Peripherally inserted central venous catheter
Intraosseous needle in the right humerus
Triple-lumen catheter in the left femoral vein
200
A 64-year-old woman has been hospitalized for 4 days for a first COPD exacerbation and is now being discharged. Before hospitalization she had mild symptoms such as breathlessness when hurrying on level ground or walking up a slight hill. She stopped smoking 7 years ago. Immunizations are up to date. Medications are a fluticasone furoate-umeclidinium-vilanterol inhaler and an additional day of prednisone.
Today, vital signs are normal. Breath sounds are distant without wheezing. Cardiovascular examination is normal.
A review of the admission chest radiograph shows homogeneous emphysema without other findings. Today, results of laboratory evaluation are normal. Spirometry shows a FEV1/FVC ratio of 0.6 and an FEV1 42% of predicted. A 6-minute walk test shows a minimum oxygen saturation of 89% with the patient breathing ambient air.
Which of the following is the most appropriate additional treatment?
Pulmonary rehabilitation
α1-Antitrypsin augmentation therapy
Lung volume reduction surgery
Supplemental home oxygen
300
A 36-year-old woman is hospitalized with community-acquired pneumonia. She has a history of systemic lupus erythematosus and Raynaud phenomenon, which have been clinically stable with nifedipine and hydroxychloroquine. Levofloxacin was initiated 2 hours ago in the emergency department.
On physical examination, temperature is 37.8 °C (100.0 °F); the remainder of the vital signs are normal. Oxygen saturation by finger pulse oximetry was initially 92% but has decreased to 84% despite the addition of supplemental oxygen at 3 L/min by nasal cannula. Pulmonary examination reveals scattered coarse rhonchi and crackles in the right lower lobe. Cardiac examination is normal. Extremities are cool.
Which of the following is the most appropriate management?
Change to earlobe pulse oximetry probe
Change to FIO2 of 0.50 by large-reservoir oxygen mask
Obtain arterial blood gases
Obtain CT angiography
300
A 23-year-old woman is evaluated for chronic cough. She reports several episodes of chronic bronchitis as a child and persistent cough productive of thick purulent sputum since childhood. She also has chronic nasal congestion and chronic diarrhea. Medications are albuterol and glucocorticoid inhalers and benzonatate as needed.
On physical examination, vital signs are normal; oxygen saturation is 96% with the patient breathing ambient air. BMI is 18. Lung examination reveals bilateral diffuse crackles. The remainder of the examination is normal.
Complete blood count and immunoglobulin levels are normal.
Chest CT scan shows bilateral upper-lobe-predominant bronchiectasis with luminal filling.
Spirometry shows an FEV1 of 68% of predicted.
Which of the following is the most likely diagnosis?
Cystic fibrosis
Allergic bronchopulmonary aspergillosis
α1-Antitrypsin deficiency
IgA deficiency
300
A 55-year-old man is evaluated in the emergency department for abdominal pain and fever of 12 hours' duration.
On physical examination, temperature is 38.3 °C (100.9 °F), blood pressure is 90/60 mm Hg, pulse rate is 110/min, and respiration rate is 26/min. Oxygen saturation is 95% with the patient breathing ambient air. The patient is confused. Scleral icterus is noted. There is tenderness to palpation in the right upper quadrant. The remainder of the examination is unremarkable.
Laboratory studies:
Leukocyte count
22,000/μL (22 × 109/L)
Alanine aminotransferase
448 U/L
Bilirubin
Total
5.0 mg/dL (85.5 μmol/L)
Direct
4.0 mg/dL (68.4 μmol/L)
Creatinine
2.0 mg/dL (176.8 μmol/L)
Lipase
56 U/L
Ultrasound of the right upper quadrant reveals a normal-appearing liver and gallbladder; the bile duct is dilated.
Which of the following is the most likely diagnosis?
Acute cholangitis
Acute cholecystitis
Pancreatitis
Pyogenic liver abscess
300
A 61-year-old woman is evaluated in the emergency department for a COPD exacerbation characterized by increased dyspnea and increased purulent sputum production. Home medications are mometasone furoate-formoterol, tiotropium bromide, and albuterol inhalers.
On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 135/82 mm Hg, pulse rate is 112/min, respiration rate is 21/min, and oxygen saturation is 94% breathing oxygen, 5 L/min by nasal cannula. Pulmonary examination reveals diffuse expiratory wheezing but no use of accessory muscles. The remainder of the physical examination is noncontributory.
Arterial blood gas studies:
pH
7.36
PCO2
43 mm Hg (5.7 kPa)
PO2
65 mm Hg (8.6 kPa)
Chest radiograph shows hyperinflation and flattened diaphragm but no infiltrate.
Nebulized albuterol and oral azithromycin are initiated.
Which of the following is the most appropriate additional management?
Prednisone
High-flow nasal cannula
Noninvasive bilevel positive airway pressure ventilation
Sputum culture
400
A 77-year-old man is evaluated in the emergency department following two episodes of melena. He reports no dyspnea or lightheadedness and no hematemesis. Medical history is significant for cirrhosis secondary to hepatitis C virus, which has previously been well compensated. He also has grade 1 esophageal varices but no history of gastrointestinal bleeding. His only medication is propranolol.
On physical examination, the patient is alert and oriented. Temperature is normal, blood pressure is 85/45 mm Hg, pulse rate is 76/min, and respiration rate is 18/min. Oxygen saturation is 97% with the patient breathing ambient air. Icterus is present. Extremities are cool to touch. The abdomen is unremarkable.
Hemoglobin is 6.5 g/dL (65 g/L).
Two peripheral intravenous lines are inserted, and fluid resuscitation with 0.9% saline is initiated.
Which of the following is the most appropriate additional treatment?
Packed red blood cell transfusion
Esophageal balloon tamponade
Norepinephrine
Transjugular intrahepatic portosystemic shunt
400
A 45-year-old woman is evaluated in the ICU for septic shock secondary to a necrotic diabetic foot infection. She has not responded to initial resuscitation with 30 mL/kg Ringer lactate infusion and vasopressor therapy. Medications are low-molecular-weight heparin, insulin glargine, norepinephrine, vasopressin, metronidazole, ceftriaxone, and vancomycin.
On physical examination, temperature is 38.6 °C (101.5 °F), blood pressure is 78/46 mm Hg, pulse rate is 102/min, and respiration rate is 16/min. Oxygen saturation is 95% with the patient breathing ambient air. A 4-cm diameter, recently debrided ulcer is present over the dorsal metacarpophalangeal joint of the great toe, extending to bone.
Which of the following is the most appropriate additional management?
Intravenous hydrocortisone
Cosyntropin stimulation test
Intravenous immune globulin
Procalcitonin measurement
400
A 28-year-old woman is evaluated in the emergency department for severe agitation. The patient is uncooperative. A friend reports that the patient had been snorting cocaine. Paroxetine and tramadol are found in the patient's backpack.
On physical examination, temperature is 39.4 °C (102.9 °F), blood pressure is 164/82 mm Hg, pulse rate is 112/min, respiration rate is 22/min, and oxygen saturation is 98% with the patient breathing ambient air. She is diaphoretic and tremulous. Myoclonus and hyperreflexia are present.
Which of the following is the most appropriate treatment?
Lorazepam
Acetaminophen
Fentanyl
Propranolol
400
A 48-year-old man is evaluated in the hospital for acute onset of hyperpyrexia and muscle rigidity. He was hospitalized 12 hours ago for upper gastrointestinal bleeding. Within the last hour he underwent upper endoscopy using rapid sequence intubation with succinylcholine and etomidate. Soon after completion of the procedure, he developed fever, tachypnea, and tachycardia.
On physical examination, temperature is 40.6 °C (105.1 °F), blood pressure is 112/68 mm Hg, pulse rate is 130/min, respiration rate is 26/min, and oxygen saturation is 99% breathing oxygen, 2 L/min by nasal cannula. He has generalized muscle rigidity and cannot open his mouth. Neurologic examination is otherwise normal.
Cooling measures are implemented.
Which of the following is the most appropriate pharmacologic treatment?
Dantrolene
Acetaminophen
Cyproheptadine
Diltiazem