7 on/ 7off
A 61-year-old man is seen for medical evaluation before a pancreaticoduodenectomy for suspected pancreatic cancer scheduled in 7 days. He reports no recent chest pain or bleeding complications after undergoing drug-eluting stent placement to the left anterior descending artery for an ST-elevation myocardial infarction 5 months ago. He has been riding his bike 10 miles daily since recovering from the myocardial infarction. Medications are aspirin, clopidogrel, losartan, atorvastatin, and atenolol.
On physical examination, vital signs are normal. Scleral icterus and jaundice are noted. Cardiac examination is normal, the lungs are clear, and the abdomen is nontender. There is no lower extremity edema.
Which of the following is the most appropriate perioperative management of this patient's antiplatelet therapy?
A) Continue clopidogrel and aspirin
B) Withhold both now
C) Withhold ASA now, continue clopidogrel
D) Withhold clopidogrel now, continue ASA
D
In patients taking dual antiplatelet therapy, if the risk of surgical delay exceeds the risk for stent thrombosis, discontinuation of the P2Y12 inhibitor can be considered after a minimum of 30 days in the case of bare metal stent placement or 3 months after drug-eluting stent placement.
A 64-year-old woman is evaluated for a 6-week history of right knee swelling and pain. She has had no recent injury, fever, or chills. She retired as a horticulturist and moved from Massachusetts to Florida 3 months ago. She takes NSAIDs, which provide partial pain relief, but the swelling persists.
On physical examination, vital signs are normal. The right knee has a moderately sized effusion but no erythema or warmth. Slight pain is present on passive movement of the knee.
Results of a Borrelia burgdorferi enzyme immunoassay are equivocal. Leukocyte count and rheumatoid factor titer are within normal limits.
Which of the following is the most appropriate next diagnostic test?
A) Borrelia burgdorferi IgG Western Blot
B) Borrelia burgdorferi IgM Western Blot
C) PCR of joint fluid
D) No further testing
A
Confirmatory serologic testing using a two-tiered diagnostic approach that includes enzyme immunoassay (EIA) and either a second EIA or IgG Western blot testing is required for definitive diagnosis of late disseminated Lyme disease.
A 77-year-old woman is evaluated during a follow-up visit for recently diagnosed nonvalvular atrial fibrillation. Medical history is significant only for hypertension. Medications are metoprolol, lisinopril, and amlodipine.
On physical examination, blood pressure is 120/65 mm Hg, pulse rate is 72/min and irregular, and respiration rate is 16/min. The remainder of the physical examination is unremarkable.
Which of the following is the most appropriate antithrombotic prophylaxis?
A) Aspirin
B) Rivaroxaban
C) Warfarin
D) None
B
The most appropriate antithrombotic prophylaxis in patients with nonvalvular atrial fibrillation is a non–vitamin K antagonist oral anticoagulant such as rivaroxaban, apixaban, edoxaban, or dabigatran.
A 45-year-old woman is evaluated for episodic nausea, bloating, and epigastric pain of 5 years' duration. In the past 3 months, the nausea has been accompanied by occasional vomiting. She also reports near-daily heartburn symptoms that have not responded to daily omeprazole. She has a 10-year history of type 2 diabetes mellitus that is treated with metformin and glyburide.
On physical examination, vital signs are normal; BMI is 29. Abdominal examination shows diffuse tenderness to deep palpation with no guarding. Other findings are normal.
Laboratory studies show a blood hemoglobin A1c level of 7.5%. The basic metabolic panel is normal. A complete blood count and liver chemistry tests are normal.
Upper endoscopy shows a moderate amount of retained food in the stomach and patchy erythema of the gastric mucosa. Biopsies of the stomach are normal.
Which of the following is the most appropriate next step in management?
A) Gastric emptying scintigraphy
B) 24-Hour pH probe
C) Initiation of domperidone
D) Initiation of metoclopramide
A
The diagnosis of gastroparesis requires the presence of specific symptoms, absence of mechanical outlet obstruction, and objective evidence of delay in gastric emptying into the duodenum.
A 22-year-old man is evaluated for an elevated serum creatinine level found during a pre-employment examination. The serum creatinine level was 1.4 mg/dL (123.8 µmol/L); the urinalysis was normal. A urine albumin-creatinine ratio obtained in preparation for this visit is 10 mg/g. The patient is a competitive weightlifter. He has no other medical problems and he takes no medications or over-the-counter supplements.
On physical examination, vital signs are normal. BMI is 29. The patient is muscular, with very little subcutaneous fat present.
Which of the following is the most appropriate management?
A) Calculate a 24-hour creatinine clearance
B) Measure blood urea nitrogen
C) Measure serum cystatin C
D) Schedule a kidney biopsy
C
Cystatin C may be preferable to creatinine to assess kidney function in individuals with higher muscle mass.
An 82-year-old woman is evaluated for severe and progressive shortness of breath on ambulation. She has COPD and has been hospitalized only once in the past 18 months for an acute exacerbation. She has not experienced an acute worsening of her symptoms, and she has minimal nonproductive cough. She stopped smoking 15 years ago. She notes that her dyspnea is a substantial impediment to her quality of life. Medical history is otherwise significant for heart failure with preserved ejection fraction. Medications are umeclidinium/vilanterol and albuterol inhalers, lisinopril, and chlorthalidone.
On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 128/78 mm Hg, pulse rate is 74/min, and respiration rate is 20/min. Oxygen saturation is 96% breathing 1 L/min of oxygen by nasal cannula and is maintained at 96% during a 6-minute walk test. Pulmonary examination reveals a prolonged expiratory phase and intermittent scattered rhonchi throughout her lung fields, with hyperresonance to percussion. Cardiac examination reveals an S4 but no murmur or jugular venous distention.
Spirometry performed 2 months ago showed an FEV1 of 42% of predicted.
Which of the following is the most appropriate treatment?
A) Furosemide
B) 2L of O2 by nasal cannula
C) Prednisone
D) Pulmonary rehabilitation
D
Pulmonary rehabilitation can provide significant benefits for patients with chronic lung disease and has been shown to improve subjective dyspnea in patients with severe COPD and following an acute exacerbation of COPD.
A 35-year-old woman is evaluated for multiple episodes of diarrhea over the past 24 hours. Two weeks ago she completed a 10-day course of oral vancomycin for a nonsevere Clostridioides difficile infection that had developed after a course of ciprofloxacin for a complicated urinary tract infection.
On physical examination, temperature is 37.3 °C (99.1 °F); the other vital signs are normal. The abdomen is not distended. Bowel sounds are present. Abdominal tenderness to palpation is minimal without guarding or rebound. Mental status is normal.
Laboratory studies show a leukocyte count of 12,000/µL (12 × 10 9/L) and serum creatinine level of 0.9 mg/dL (79.6 µmol/L).
Stool polymerase chain reaction assay is positive for C. difficile toxin gene.
Which of the following is the most appropriate treatment?
A) Oral fidaxomicin
B) Oral metronidazole
C) Oral vancomycin and IV metronidazole
D) Probiotics
A
For a first recurrence of Clostridioides difficile infection initially treated with vancomycin, oral fidaxomicin can be used; a prolonged and pulsed oral vancomycin regimen can also be used if oral vancomycin or fidaxomicin was used to treat the initial episode.
A 35-year-old woman is evaluated for exertional dyspnea of 6 months' duration. She reports no other symptoms. Medical history is unremarkable, and she takes no medications.
On physical examination, vital signs are normal. Oxygen saturation is 96% breathing ambient air. The estimated central venous pressure is elevated. Apical impulse is normal; a parasternal impulse is noted at the left sternal border. A soft systolic murmur is heard at the second left intercostal space, and a diastolic flow rumble is heard at the left sternal border. Fixed splitting of the S2 is noted throughout the cardiac cycle. The remainder of the physical examination is normal.
An electrocardiogram demonstrates right axis deviation and incomplete right bundle branch block.
Which of the following is the most likely diagnosis?
A) ASD
B) Bicuspid aortic valve with stenosis
C) Congenital pulmonic stenosis
D) Mitral stenosis
A
Elevated central venous pressure, fixed splitting of the S2, a right ventricular heave, and right-axis deviation and incomplete right bundle branch block on electrocardiogram are characteristic findings in patients with ostium secundum atrial septal defect.
A 21-year-old woman is evaluated at 26 weeks' gestation. She has chronic hepatitis B virus (HBV) infection acquired through vertical transmission. She is in the immune-tolerant phase, characterized by positive hepatitis B surface antigen and hepatitis B e antigen, HBV DNA level of 1.1 million IU/mL, and normal aminotransferase levels. The patient reports feeling well. Her only medication is a prenatal vitamin.
Which of the following is the most appropriate next step in management?
A) Hepatitis B antiviral treatment
B) Hepatitis B immunization and immune globulin
C) Monitoring of hepatitis B virus DNA level
D) No additional testing or intervention
A
Pregnant women who have hepatitis B virus DNA levels greater than 200,000 IU/mL at 24 to 28 weeks' gestation should be treated with hepatitis B antiviral therapy to prevent vertical transmission during delivery.
A 59-year-old woman is evaluated during a routine follow-up visit. She was recently diagnosed with type 2 diabetes mellitus and hyperlipidemia. She feels well. Medications are metformin and atorvastatin.
Physical examination findings and vital signs are normal. BMI is 27.
Laboratory studies show a serum creatinine level of 0.9 mg/dL (79.6 µmol/L), an estimated glomerular filtration rate greater than 60 mL/min/1.73 m2, and normal urinalysis results.
Which of the following is the most appropriate diagnostic test to perform next?
A) 24-Hour urine collection for protein
B) Kidney ultrasonography
C) Spot urine albumin–creatinine ratio
D) No additional testing
C
The National Kidney Foundation and the American Diabetes Association recommend annual testing by measuring the albumin–creatinine ratio to assess urine albumin excretion in patients with type 1 diabetes mellitus of 5 years' duration and in all patients with type 2 diabetes starting at the time of diagnosis.
A 49-year-old man was admitted to the ICU 3 days ago with sepsis secondary to health care–associated pneumonia. He is now being transferred to the general medical floor. Medical history is significant for spinal cord injury with associated lower extremity paralysis and neurogenic bladder. He is able to perform intermittent bladder catheterization. Medications are baclofen, enoxaparin, and levofloxacin.
On physical examination, vital signs are normal. BMI is 19. Left lower lobe crackles are present on lung auscultation. There is flaccid paralysis of the lower extremities. Skin is intact without erythema over pressure points.
Which of the following is the most appropriate intervention to prevent the development of a pressure injury?
A) Advanced static mattress
B) Air mattress
C) Frequent repositioning
D) Zinc supplementation
A
An advanced static mattress or mattress overlay made of specialized sheepskin, foam, or gel provides the best protection against the development of pressure injuries in hospitalized patients.
A 25-year-old woman is hospitalized with a 4-day history of fever and cough productive of brown sputum. She is at 14 weeks' gestation with her first pregnancy. Medical history is significant for mild persistent asthma. Medications are an albuterol inhaler, beclomethasone inhaler, and a prenatal vitamin.
On physical examination, temperature is 38.2 °C (100.8 °F), blood pressure is normal, pulse rate is 122/min, and respiration rate is 24/min. Oxygen saturation is 94% breathing ambient air. Crackles are heard at the left lung base on pulmonary auscultation.
Chest radiograph shows a left lower lobe infiltrate.
Which is the most likely organism causing this patient's pneumonia?
A) E. Coli
B) Klebsiella
C) Listeria
D) S. Aureus
E) S. Pneumo
E
The microbiology of community-acquired pneumonia in pregnancy is similar to that seen in the general population; among patients requiring hospitalization, the most common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms, including Legionella species, Chlamydia pneumoniae, and Mycoplasma pneumoniae.
A 26-year-old woman is evaluated for a preconception assessment. She has Marfan syndrome. She reports no cardiovascular symptoms. Her only medication is long-acting metoprolol.
On physical examination, blood pressure is 110/60 mm Hg, and pulse rate is 60/min and regular. The patient has facial and skeletal features of Marfan syndrome. The estimated central venous pressure is normal. Cardiac examination reveals a normal apical impulse, normal S1 and S2, and a grade 2/6 late-peaking systolic murmur and midsystolic click over the apex. The lungs are clear to auscultation. No edema is noted.
Transthoracic echocardiogram demonstrates a dilated proximal ascending aorta with a dimension of 4.6 cm. No aortic regurgitation is appreciated. Bileaflet mitral valve prolapse is noted with mild mitral regurgitation. The left ventricular size and function are normal. There is no recent echocardiogram for comparison.
Which of the following is the most appropriate management?
A) Advise against pregnancy
B) Proceed with mitral valve intervention
C) Repeat echocardiography in 12 months
D) Switch metoprolol to losartan
A
Women with Marfan syndrome have an increased risk for pregnancy-related aortic dissection and rupture.
A 55-year-old woman is evaluated after screening colonoscopy showed three polyps at the rectosigmoid junction. The three polyps were 3 mm, 5 mm, and 6 mm in size. All three polyps were completely excised and pathology showed them to be hyperplastic. Colonoscopy preparation was excellent and the procedure was complete to the cecum. Family history is significant for colon cancer diagnosed in her paternal grandfather at age 80 years.
All physical examination findings, including vital signs, are normal.
When should this patient next undergo colonoscopy?
A) 1 year
B) 3 years
C) 5 years
D) 10 years
On physical examination, BMI is 29; all other findings are unremarkable.
Which of the following is the most appropriate next step in management?
A) Colonoscopy
B) Glucose breath test
C) Polyethylene glycol 3350
D) Serum tissue transglutaminase antibody measurement
D
Patients with small (<10 mm) hyperplastic polyps on baseline colonoscopic examination should undergo surveillance colonoscopy in 10 years.
A 70-year-old man is evaluated for a recent onset of macroscopic hematuria. History is significant for end-stage kidney disease and hypertension. He has been on hemodialysis for 3 years. Urine output is approximately 250 mL/d. Medications are sevelamer, sodium bicarbonate, lisinopril, and amlodipine.
On physical examination, blood pressure is 150/90 mm Hg, and pulse rate is 70/min. Bilateral flank tenderness is noted. There is no abdominal mass.
Laboratory studies show a hemoglobin level of 15 g/dL (150 g/L).
Kidney ultrasound shows several complex cysts and two bilateral solid masses.
Which of the following is the most appropriate management?
A) Bilateral partial nephrectomy
B) Bilateral radical nephrectomy
C) Percutaneous kidney biopsy
D) Surveillance ultrasonography
B
Patients with end-stage kidney disease have a markedly increased risk for renal cell carcinoma, and a high level of suspicion is warranted in patients with symptoms such as new-onset gross hematuria or unexplained flank pain.
A 49-year-old man is hospitalized for a 4-day history of poorly controlled nausea, vomiting, fatigue, and volume depletion. He has locally advanced esophageal adenocarcinoma and is undergoing neoadjuvant chemoradiation therapy. Radiation therapy is administered daily, and chemotherapy with low-dose carboplatin plus paclitaxel is administered weekly. His nausea and vomiting are temporally related to the radiation therapy. Medical history is otherwise significant for previous tobacco use. Other medications are acetaminophen, docusate sodium, bisacodyl, oxycodone, and prochlorperazine.
On physical examination, the patient appears fatigued. Blood pressure is 110/68 mm Hg, and pulse rate is 96/min; the remaining vital signs are normal. Pain is elicited with deep palpation of the epigastrium.
Which of the following is the most appropriate initial treatment of this patient's nausea?
A) Haloperidol
B) Olanzapine
C) Ondansetron
D) Synthetic oral cannabinoids
C
A 5-hydroxytryptamine-3 (5-HT3) antagonist, such as ondansetron, is the preferred initial agent for radiation-induced nausea and vomiting.
A 20-year-old man is evaluated for a scratch on his right arm that occurred 3 weeks ago while playing with a pet kitten. The patient now has a skin lesion at the inoculation site and painful swelling in the ipsilateral axillary area. He is also experiencing malaise. Medical history is unremarkable.
On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 120/80 mm Hg, pulse rate is 80/min, and respiration rate is 18/min. A red papule is present on the biceps area of the right arm, and tender right axillary lymphadenopathy with overlying erythema is noted. The remainder of the examination is normal.
Laboratory studies indicate a leukocyte count of 11,500/µL (11.5 × 109/L) with 83% neutrophils and 17% lymphocytes.
Which of the following is the most appropriate treatment?
A) Azithromycin
B) Dicloxacillin
C) Itraconazole
D) Linezolid
A
Azithromycin is an effective antibiotic agent for treatment of cat-scratch disease.
A 67-year-old man is evaluated during a follow-up visit. Medical history is significant for a 7-year history of heart failure with placement of an implantable cardioverter-defibrillator 6 years ago. He has New York Heart Association functional class II symptoms and is currently stable. Since his last visit 6 months ago, he has had no changes in medications, symptoms, or other medical issues. Medications are valsartan-sacubitril, carvedilol, furosemide, and spironolactone.
On physical examination, the patient is afebrile, blood pressure is 108/74 mm Hg, and pulse rate is 64/min. He has no jugular venous distention or S3. No edema is noted.
An echocardiogram obtained 1 year ago demonstrated a left ventricular ejection fraction of 25% and left ventricular end-diastolic diameter of 6.7 cm; these findings are unchanged from 2 years ago.
Heart failure education and the need for diet and medication adherence are reinforced.
Which of the following is the most appropriate testing to perform at this visit?
A) Echocardiography
B) 24-Hour ambulatory electrocardiographic monitoring
C) Serum B-type natriuretic peptide level measurement
D) Serum electrolyte measurement and kidney function studies
D
In patients with heart failure, each follow-up visit should include evaluation of current symptoms and functional capacity; assessment of volume status, electrolytes, and kidney function; and review of the patient's medication regimen for adequacy.
A 52-year-old man is evaluated for dysphagia of 3 months' duration. He reports regurgitating undigested food soon after eating solid food, occasional coughing and choking after swallowing, and chronic halitosis. He reports no weight loss or chest pain. He drinks two beers weekly and does not smoke.
On physical examination, vital signs are normal; BMI is 25. The remainder of the examination, including abdominal examination, is unremarkable.
Which of the following is the most appropriate diagnostic test to perform next?
A) Barium esophagography
B) Esophageal manometry
C) 24-Hour esophageal pH monitoring
D) Upper endoscopy
A
Patients with dysphagia associated with regurgitation of undigested food should be evaluated with a barium esophagram for the presence of a Zenker diverticulum.
A 72-year-old woman is evaluated during a routine visit. History is significant for hypertension treated with amlodipine and losartan. She has no other medical problems. She remains physically active and routinely plays tennis and golf.
On physical examination, blood pressure is 142/84 mm Hg, and pulse rate is 72/min; other vital signs are normal. BMI is 24. The remainder of the examination is unremarkable.
Laboratory studies show a serum creatinine level of 0.8 mg/dL (70.7 µmol/L) and a serum potassium level of 4.0 mEq/L (4.0 mmol/L).
According to the target blood pressure goals recommended by the American College of Physicians and the American Academy of Family Physicians, which of the following would be an appropriate management?
A) Add chlorthalidone
B) Increase the amlodipine dose
C) Increase the losartan dose
D) Make no changes to antihypertensive medications
D
Based on evidence that the greatest absolute benefit of antihypertensive therapy is seen in patients with the highest blood pressure and cardiovascular risk, the American College of Physicians and American Academy of Family Physicians recommend that antihypertensive drugs be initiated in patients ≥60 years old if blood pressure is >150/90 mm Hg, with a goal of reducing systolic blood pressure to <150 mm Hg; the American College of Cardiology/American Heart Association recommends a systolic blood pressure target of <130 mm Hg in patients ≥65 years old.
A 61-year-old man is evaluated in an urgent care center for acute frontal headache and pain in the right eye that began a few hours earlier while he was watching his grandson's basketball game. The pain extends through the anterior scalp and downward across the nose. The patient is also nauseated and vomiting acutely. He has photophobia and notes that lights appear “fuzzy.” Medical history is significant for hypertension and anxiety. Medications are hydrochlorothiazide and citalopram.
On physical examination, blood pressure is 150/90 mm Hg; other vital signs are normal. Severe conjunctival erythema; photophobia; a mid-dilated, nonreactive pupil on the right side; and corneal cloudiness are noted. Upon gentle palpation of the eyes, tenderness and increased firmness are noted over the right globe compared with the left. Right eye visual acuity is grossly decreased. No discharge is noted.
Which of the following is the most likely diagnosis?
A) Acute angle-closure glaucoma
B) Bacterial endophthalmitis
C) Central retinal vein occlusion
D) Scleritis
A
Characteristic features of acute angle-closure glaucoma include the sudden onset of headache, nausea, vomiting, and vision changes; the appearance of halos around lights; and the presence of a mid-dilated, nonreactive pupil.
A 31-year-old man undergoes pretravel consultation. He plans to leave in 8 days for a safari trip to Kenya. He received yellow fever and typhoid vaccinations 18 months ago, and he is undergoing a work-related three-dose hepatitis B vaccination series. He also has a prescription for prophylactic antimalarial medication. No serum IgG antibodies to hepatitis A were detected in a recent blood test. He smokes cigarettes and occasionally drinks an alcoholic beverage.
On physical examination, vital signs are normal, and other findings are unremarkable.
Which of the following is the most appropriate pretravel management for this patient?
A) First dose of hepatitis A vaccine with a second dose in 7 days
B) Immune globulin
C) Single dose of hepatitis A vaccine
D) Single dose of hepatitis A vaccine plus immune globulin
E) No intervention
C
Hepatitis A vaccination should ideally occur 2 to 4 weeks before travel to an endemic region; however, a single dose of the vaccine given any time before travel provides adequate protection to otherwise healthy persons.
A 52-year-old man is evaluated during a visit to establish care. He is asymptomatic, but he is seeking advice on how to modify his risk for cardiovascular disease. He drinks one glass of wine with dinner most nights, and he quit smoking 12 years ago. Family history is significant for a myocardial infarction in his father at age 61 years. He takes no medications. The patient is Hispanic.
On physical examination, temperature is normal, blood pressure is 128/76 mm Hg, and pulse rate is 74/min. BMI is 28. The remainder of the physical examination is unremarkable.
Which of the following risk factors most increases this patient's risk for cardiovascular disease?
A) Alcohol use
B) Ethnicity
C) Family history
D) Hyperlipidemia
E) Smoking history
D
Most cardiovascular risk can be attributed to modifiable risk factors; among them, elevated lipid levels impart the highest risk for cardiovascular disease.
A 75-year-old man is evaluated for progressive dysphagia of 8 months' duration for both solid food and water, and the necessity to induce vomiting several times each month to relieve his symptoms. He also has experienced chest pain and heartburn symptoms. He has lost approximately 6 kg (13 lb) of weight over the preceding 3 months and a total of 9 kg (20 lb) since his symptoms began. He has a long history of cigarette and alcohol use. His medical history and review of systems is otherwise negative. He has no travel history outside the northeastern United States. He takes no medication.
On physical examination, vital signs are normal; BMI is 23. He appears thin and tired. The remainder of the physical examination is unremarkable.
Upper endoscopic findings reveal retained saliva, liquid, and food in the esophagus without mechanical obstruction. Manometry demonstrates incomplete lower esophageal relaxation and aperistalsis.
Which of the following is the most likely diagnosis?
A) Achalasia
B) Chagas disease
C) Eosinophilic esophagitis
D) Pseudoachalasia
D
Pseudoachalasia is caused by a tumor at the gastroesophageal junction infiltrating the myenteric plexus causing esophageal motor abnormalities; symptoms, barium-imaging and manometric findings, and endoscopic appearance are similar to achalasia.
A 72-year-old man is evaluated in the hospital after developing acute kidney injury 2 days following coronary artery bypass grafting. He is currently on mechanical ventilation and requires vasopressors for hypotension. He underwent coronary angiography 12 hours prior to surgery. The serum creatinine has increased from 0.8 mg/dL (70.7 µmol/L) at baseline to 2.2 mg/dL (194.5 µmol/L), and urine output has decreased to 350 mL/24 h. History is significant for type 2 diabetes mellitus and coronary artery disease. Current medications are intravenous furosemide, insulin, propofol, fentanyl, and norepinephrine.
On physical examination, the patient is intubated and mechanically ventilated. A urinary catheter is in place. Temperature is 37.9 °C (100.2 °F), blood pressure is 98/60 mm Hg, pulse rate is 105/min, respiration rate is 28/min, and oxygen saturation is 96% on 30% FIO2. There is no rash. Decreased breath sounds are heard in the lung bases. The remainder of the examination is noncontributory.
Which of the following is the most appropriate test to perform next?
A) Examination of urine sediment
B) Fractional excretion of sodium
C) Kidney ultrasonography
D) Measurement of central venous pressure
A
The presence of granular casts and/or renal epithelial cells on urine microscopy has strong predictive value for acute tubular necrosis.