Medication prioritization US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Medication prioritization. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Medication prioritization US Medical PG Question 1: A 70-year-old female with a history of congestive heart failure presents to the emergency room with dyspnea. She reports progressive difficulty breathing which began when she ran out of her furosemide and lisinopril prescriptions 1-2 weeks ago. She states the dyspnea is worse at night and when lying down. She denies any fever, cough, or GI symptoms. Her medication list reveals she is also taking digoxin. Physical exam is significant for normal vital signs, crackles at both lung bases and 2+ pitting edema of both legs. The resident orders the medical student to place the head of the patient's bed at 30 degrees. Additionally, he writes orders for the patient to be given furosemide, morphine, nitrates, and oxygen. Which of the following should be checked before starting this medication regimen?
- A. Basic metabolic panel (Correct Answer)
- B. Complete blood count
- C. Brain natriuretic peptide
- D. Urinalysis
- E. Chest x-ray
Medication prioritization Explanation: ***Basic metabolic panel***
- A **basic metabolic panel (BMP)** is essential before starting this regimen to assess **kidney function** (creatinine, BUN) and **electrolytes**, particularly **potassium**.
- **Critical safety consideration**: The patient is on **digoxin**, which has significantly increased toxicity when potassium is low. Furosemide (a loop diuretic) causes potassium loss, making baseline potassium assessment essential to prevent life-threatening digoxin toxicity.
- **Renal function** must be checked before administering furosemide and lisinopril, both of which are renally cleared and can worsen renal function or accumulate in renal impairment.
*Complete blood count*
- A **complete blood count (CBC)** assesses for anemia, infection, and hematologic abnormalities.
- While potentially useful, it doesn't provide the immediate biochemical information (renal function, electrolytes) needed to safely initiate the prescribed heart failure medications, especially given the digoxin interaction risk.
*Brain natriuretic peptide*
- **Brain natriuretic peptide (BNP)** is a biomarker of heart failure severity and can help differentiate cardiac from non-cardiac causes of dyspnea.
- However, this patient's clinical presentation (orthopnea, bilateral crackles, pitting edema, medication non-adherence) already strongly confirms acute decompensated heart failure, making BNP less critical than checking renal function and electrolytes before medication administration.
*Urinalysis*
- **Urinalysis** can detect urinary tract infections, proteinuria, or other renal abnormalities.
- This patient's symptoms are classic for acute decompensated heart failure due to medication non-adherence, making urinalysis less immediately relevant for managing her acute presentation and medication safety.
*Chest x-ray*
- A **chest x-ray** can confirm pulmonary edema (cardiomegaly, cephalization, Kerley B lines) and rule out other causes of dyspnea like pneumonia or pneumothorax.
- While important for confirming the diagnosis, it is not required **before** starting medications and does not provide the critical biochemical information (renal function, electrolytes) needed to safely administer diuretics and ACE inhibitors in a patient on digoxin.
Medication prioritization US Medical PG Question 2: An 82-year-old woman comes to the physician because of difficulty sleeping and increasing fatigue. Over the past 3 months she has been waking up early and having trouble falling asleep at night. During this period, she has had a decreased appetite and a 3.2-kg (7-lb) weight loss. Since the death of her husband one year ago, she has been living with her son and his wife. She is worried and feels guilty because she does not want to impose on them. She has stopped going to meetings at the senior center because she does not enjoy them anymore and also because she feels uncomfortable asking her son to give her a ride, especially since her son has had a great deal of stress lately. She is 155 cm (5 ft 1 in) tall and weighs 51 kg (110 lb); BMI is 21 kg/m2. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, she is tired and has a flattened affect. Cognition is intact. Which of the following is the most appropriate initial step in management?
- A. Begin mirtazapine therapy
- B. Begin cognitive-behavioral therapy
- C. Notify adult protective services
- D. Assess for suicidal ideation (Correct Answer)
- E. Recommend relocation to a nursing home
Medication prioritization Explanation: ***Assess for suicidal ideation***
- The patient exhibits several **risk factors for depression**, including **insomnia**, **early morning awakening**, **anorexia**, **weight loss**, and significant **anhedonia** (lack of enjoyment in activities).
- Given her age, recent loss of her husband, social withdrawal, feelings of guilt, and significant emotional distress, it is crucial to first assess for **suicidal ideation** before initiating other treatments.
- **Elderly patients with depression have elevated suicide risk**, especially with recent bereavement and social isolation. Safety assessment is the **mandatory first step** in managing any patient with major depressive symptoms.
*Begin mirtazapine therapy*
- While **mirtazapine** is an effective antidepressant that could address several of her symptoms (insomnia, poor appetite, depression), it should only be considered after a **thorough safety assessment**, particularly for suicide risk.
- Starting medication without assessing for immediate danger may overlook critical safety concerns.
*Begin cognitive-behavioral therapy*
- **Cognitive-behavioral therapy (CBT)** is an effective treatment for depression and could be beneficial for this patient.
- However, similar to medication, it is a subsequent treatment step. The immediate priority is to rule out **suicidal intent** given the severity of her depressive symptoms.
*Notify adult protective services*
- There is no direct evidence of **abuse or neglect** in the provided information that would warrant involving adult protective services.
- Her feelings of guilt and worry about burdening her family, while contributing to her depression, do not indicate that her son or daughter-in-law are harming her.
*Recommend relocation to a nursing home*
- While the patient is elderly and potentially depressed, there is no medical or social necessity presented that indicates she requires or would benefit from a **nursing home** at this stage.
- This step would be premature and does not address the immediate mental health concerns or potential safety issues.
Medication prioritization US Medical PG Question 3: A 59-year-old woman comes to the emergency department because of a 2-day history of worsening fever, chills, malaise, productive cough, and difficulty breathing. Three days ago, she returned from a trip to South Africa. She has type 2 diabetes mellitus, hypertension, and varicose veins. Her current medications include metformin, lisinopril, and atorvastatin. Her temperature is 39.4°C (102.9°F), pulse is 102/minute, blood pressure is 94/68 mm Hg, and respirations are 31/minute. Pulse oximetry on 2 L of oxygen via nasal cannula shows an oxygen saturation of 91%. Examination reveals decreased breath sounds and dull percussion over the left lung base. The skin is very warm and well-perfused. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 11.6 g/dL
Leukocyte count 15,400/mm3
platelet count 282,000/mm3
Serum
Na+ 144 mEq/L
Cl- 104 mEq/L
K+ 4.9 mEq/L
Creatinine 1.5 mg/dL
Blood and urine for cultures are obtained. Intravenous fluid resuscitation is begun. Which of the following is the next best step in management?
- A. Erythromycin
- B. Intravenous ceftriaxone and azithromycin (Correct Answer)
- C. External cooling and intravenous acetaminophen
- D. Intravenous vancomycin and ceftriaxone
- E. CT of the chest with contrast
Medication prioritization Explanation: ***Intravenous ceftriaxone and azithromycin***
* This patient presents with **severe community-acquired pneumonia (CAP)** meeting criteria for ICU-level care, including hypotension (94/68 mm Hg), hypoxemia requiring supplemental oxygen, tachypnea (31/min), and altered mental status indicators. The presentation meets multiple **severe CAP criteria** (CURB-65 score ≥3 or IDSA/ATS major criteria).
* **Intravenous ceftriaxone** (a third-generation cephalosporin) provides broad-spectrum coverage against common bacterial causes of CAP, including *Streptococcus pneumoniae* and *Haemophilus influenzae*. **Azithromycin** (a macrolide) is crucial to cover atypical pathogens like *Mycoplasma pneumoniae*, *Chlamydophila pneumoniae*, and *Legionella pneumoniae*.
* This combination represents the **standard empiric therapy for severe CAP** per IDSA/ATS guidelines. The patient's recent travel to South Africa and severe symptoms increase the likelihood of atypical pathogens or resistant strains, making dual therapy essential.
*Erythromycin*
* While erythromycin is a macrolide that covers atypical pathogens, its use is generally limited due to higher rates of gastrointestinal side effects and a less favorable dosing profile compared to newer macrolides like azithromycin. It does not provide adequate coverage for typical bacterial causes of CAP.
* In severe CAP with signs of sepsis, monotherapy with erythromycin would be insufficient and would not address the need for broad-spectrum coverage against both typical and atypical bacteria. Dual antibiotic therapy is required for severe cases.
*External cooling and intravenous acetaminophen*
* These interventions are appropriate for **fever reduction** but do not address the underlying severe infection (pneumonia with sepsis). While important for symptomatic relief, they are not the "next best step in management" for a life-threatening condition.
* Treating the infection with appropriate antibiotics is paramount to prevent further deterioration and organ damage. In severe sepsis from pneumonia, **source control through antimicrobial therapy takes precedence** over symptomatic fever management.
*Intravenous vancomycin and ceftriaxone*
* **Vancomycin** is primarily used to cover **methicillin-resistant *Staphylococcus aureus* (MRSA)**. While MRSA can cause severe pneumonia, there are no specific risk factors for MRSA in this patient (e.g., recent hospitalization, IV drug use, prior MRSA infection, severe influenza, cavitary lesions, hemoptysis).
* Adding vancomycin without specific indications for MRSA coverage would represent unnecessary broad-spectrum antibiotic use and could contribute to antibiotic resistance. The combination of **ceftriaxone and azithromycin is the standard empiric therapy** for severe CAP without MRSA risk factors.
*CT of the chest with contrast*
* A CT scan of the chest might be useful for further characterizing the pneumonia, identifying complications (e.g., empyema, abscess), or differentiating from other conditions **after initial stabilization**. However, in a patient with severe pneumonia, hypoxemia, and hypotension, the immediate priority is stabilization and initiation of empiric antibiotic therapy.
* Delaying life-saving antibiotic treatment to obtain a CT scan could worsen the patient's prognosis and violate the principle of **early appropriate antibiotics in sepsis** (ideally within 1 hour). Clinical diagnosis with chest X-ray is sufficient to initiate treatment, and further imaging can be obtained after stabilization if needed.
Medication prioritization US Medical PG Question 4: A 16-year-old boy with history of seizure disorder is rushed to the Emergency Department with multiple generalized tonic-clonic seizures that have spanned more than 30 minutes in duration. He has not regained consciousness between these episodes. In addition to taking measures to ensure that he maintains adequate respiration, which of the following is appropriate for initial pharmacological therapy?
- A. Carbamazepine
- B. Gabapentin
- C. Lorazepam (Correct Answer)
- D. Valproic acid
- E. Phenytoin
Medication prioritization Explanation: ***Lorazepam***
- This patient is experiencing **status epilepticus**, defined by continuous seizures lasting over 5 minutes or recurrent seizures without regaining consciousness. **Intravenous benzodiazepines**, like lorazepam, are the first-line treatment due to their rapid onset of action on GABA receptors.
- **Lorazepam** is preferred over other benzodiazepines in this setting due to its relatively **longer duration of action** and availability as an intravenous formulation, effectively terminating the acute seizure.
*Carbamazepine*
- **Carbamazepine** is an oral **anti-epileptic drug** used for long-term control of focal seizures, but it is not suitable for acute management of status epilepticus due to its **slow onset of action** and lack of intravenous formulation for rapid effect.
- It works by blocking **voltage-gated sodium channels**, which is not the primary mechanism for immediate seizure termination in an emergency.
*Gabapentin*
- **Gabapentin** is an anti-epileptic medication primarily used for focal seizures and neuropathic pain, and is **not effective** in treating acute generalized tonic-clonic seizures or status epilepticus.
- Its mechanism of action involves modulation of **calcium channels** and GABA, but it has a **slow onset** and limited efficacy in acute seizure termination.
*Valproic acid*
- **Valproic acid** can be used in the long-term management of various seizure types, including generalized tonic-clonic seizures, and has an intravenous formulation, but it is **not the first-line choice for immediate termination** of status epilepticus.
- Benzodiazepines are typically administered first, and if they fail, valproic acid can be considered as a **second-line agent** along with other antiepileptics.
*Phenytoin*
- **Phenytoin** is a classic anti-epileptic drug that can be used intravenously as a **second-line agent** for status epilepticus if benzodiazepines are unsuccessful.
- It has a slower onset of action compared to benzodiazepines and carries risks such as **cardiac arrhythmias** and **hypotension** with rapid infusion, making it less ideal for initial therapy.
Medication prioritization US Medical PG Question 5: A 52-year-old unconscious man is brought to the emergency department. He was found unresponsive on the sidewalk in the snow. He is recognized by the staff as a local homeless man and IV drug user. Rapid warming procedures are initiated. At physical examination, he is dirty and disheveled and unrousable with a blood pressure of 100/76 mm Hg and a temperature of 37.2°C (99°F). He is thin with apparent weight loss. Both arms have indications of recent IV injection stigmata. A head MRI reveals multiple hyperintense signals in the meninges with multiple tiny contrast-enhancing lesions in the cerebellum and cerebral cortex. A chest X-ray is within normal limits. Mild dilatation of the ventricles is also appreciated. Cerebrospinal fluid (CSF) analysis reveals:
CSF opening pressure 25 cm H20
CSF total leukocyte count 580/mm3
Lymphocytes 90%
Neutrophils 10%
CSF protein 176 mg/dL
CSF glucose 21 mg/dL
A specimen stains are positive for acid-fast bacilli. CSF culture is pending. Appropriate antibacterial medication is initiated. Which of the following is true regarding the immediate future management of this patient?
- A. Treatment should only be started after CSF culture results
- B. Check liver enzymes regularly
- C. Verify response to antibiotic therapy
- D. Acyclovir should be started empirically as well
- E. Steroids should be considered (Correct Answer)
Medication prioritization Explanation: ***Steroids should be considered***
- The patient has **tuberculous meningitis**, evidenced by the presence of **acid-fast bacilli** in the CSF, lymphocytic pleocytosis, high protein, and low glucose. **Corticosteroids** (e.g., dexamethasone) are recommended in conjunction with anti-TB drugs for tuberculous meningitis to reduce inflammation, cerebral edema, and improve outcomes, especially in severe cases.
- The MRI findings of **meningeal enhancement** and **hydrocephalus**, along with the patient's unconscious state, indicate severe inflammation, making steroid use crucial to mitigate neurological sequelae.
*Treatment should only be started after CSF culture results*
- This is incorrect because **tuberculous meningitis** is a severe and rapidly progressive condition where delaying treatment can lead to significant morbidity and mortality.
- The **acid-fast bacilli stain** is a strong indicator, and empirical anti-TB therapy should be initiated immediately based on clinical suspicion and direct microscopy findings, without waiting for culture results which can take weeks.
*Check liver enzymes regularly*
- While it is important to monitor liver enzymes due to the potential **hepatotoxicity** of anti-tuberculous drugs (especially isoniazid and rifampin), this is a routine monitoring measure rather than an immediate management decision regarding treatment initiation or adjunctive therapies in this acute setting.
- It is an important part of the overall management plan but does not address the immediate, critical decisions about the patient's current severe neurological infection.
*Verify response to antibiotic therapy*
- This is an important long-term aspect of management, but it is not an immediate action. Verifying response typically involves clinical improvement, repeat CSF analysis, and sometimes imaging, which occurs after the initial treatment has been commenced and had time to act.
- The immediate concern is to initiate the most effective and comprehensive treatment upfront, including adjunctive steroids, given the severity of the condition.
*Acyclovir should be started empirically as well*
- This is incorrect because the CSF analysis with **acid-fast bacilli** staining has already strongly pointed towards a bacterial (specifically mycobacterial) infection, making **viral encephalitis** less likely as the primary diagnosis.
- There are no specific clinical or laboratory findings (e.g., temporal lobe involvement on MRI, absence of AFB) that would merit empirical antiviral therapy with acyclovir in this context, especially when a clear bacterial pathogen has been identified.
Medication prioritization US Medical PG Question 6: A 53-year-old woman with type 2 diabetes mellitus is admitted for evaluation of recurrent episodes of nausea, tremors, and excessive sweating. She works as a nurse and reports self-measured blood glucose levels below 50 mg/dL on several occasions. Her family history is positive for borderline personality disorder. The only medication listed in her history is metformin. Which of the following is the most appropriate next step in management?
- A. Measure serum C-peptide concentration
- B. Ask the patient if she is taking any medications other than metformin (Correct Answer)
- C. Search the patient's belongings for insulin
- D. Measure glycated hemoglobin concentration
- E. Report the patient to her employer
Medication prioritization Explanation: ***Ask the patient if she is taking any medications other than metformin***
- The patient's presentation with recurrent **hypoglycemic symptoms** (nausea, tremors, sweating) and documented low blood glucose, while only being prescribed metformin (which does not cause hypoglycemia), strongly suggests **exogenous insulin or sulfonylurea use**.
- A direct question about other medications is a crucial initial step to ascertain the cause of her hypoglycemia and to rule out **factitious hypoglycemia**, especially given her profession as a nurse and a family history that might suggest psychological vulnerabilities, although not a direct diagnosis for the patient.
*Measure serum C-peptide concentration*
- While **low C-peptide** in the presence of hypoglycemia would suggest exogenous insulin administration, and high C-peptide might point to an insulinoma, this test should be done *after* ruling out common causes like the undisclosed use of other medications.
- This is a more invasive and less direct initial step compared to simply asking the patient about medication use, especially when a readily reversible cause (undisclosed medication) is possible.
*Search the patient's belongings for insulin*
- Searching a patient's belongings without their consent is a serious ethical breach and a violation of privacy.
- This action should only be considered as a last resort in extreme circumstances and with appropriate legal and ethical oversight, not as an initial diagnostic step.
*Measure glycated hemoglobin concentration*
- **Glycated hemoglobin (HbA1c)** reflects average blood glucose levels over the past 2-3 months and is used to monitor long-term glycemic control in diabetic patients.
- While useful for diabetes management, it will not directly identify the acute cause of recurrent hypoglycemic episodes or distinguish between endogenous and exogenous insulin sources.
*Report the patient to her employer*
- Reporting the patient to her employer prematurely, without a definitive diagnosis or understanding the full context of her condition, is unethical and unprofessional.
- The immediate priority is to diagnose and manage the patient's medical condition, ensuring her safety and well-being, before considering professional implications.
Medication prioritization US Medical PG Question 7: A previously healthy 5-year-old boy is brought to the emergency department because of a 1-day history of high fever. His temperature prior to arrival was 40.0°C (104°F). There is no family history of serious illness. Development has been appropriate for his age. He is administered rectal acetaminophen. While in the waiting room, he becomes unresponsive and starts jerking his arms and legs back and forth. A fingerstick blood glucose concentration is 86 mg/dL. After 5 minutes, he continues having jerky movements and is unresponsive to verbal and painful stimuli. Which of the following is the most appropriate next step in management?
- A. Intravenous administration of lorazepam (Correct Answer)
- B. Intravenous administration of phenobarbital
- C. Obtain blood cultures
- D. Intravenous administration of valproate
- E. Intravenous administration of fosphenytoin
Medication prioritization Explanation: ***Intravenous administration of lorazepam***
- The child is experiencing a **prolonged seizure** (greater than 5 minutes) following a high fever, which is concerning for **status epilepticus** secondary to a febrile seizure.
- **Lorazepam** is a first-line benzodiazepine for status epilepticus due to its rapid onset of action and prolonged anticonvulsant effect.
*Intravenous administration of phenobarbital*
- **Phenobarbital** is a long-acting anticonvulsant often used for **refractory status epilepticus** or as a long-term maintenance therapy.
- It is not the preferred initial treatment for an acute, prolonged seizure due to its slower onset compared to benzodiazepines.
*Obtain blood cultures*
- While obtaining blood cultures is important for identifying potential sources of infection causing the fever, it is **not the immediate priority** when a child is actively seizing and unresponsive.
- **Seizure termination** takes precedence to prevent potential neurological injury.
*Intravenous administration of valproate*
- **Valproate** is an anticonvulsant that can be used for various seizure types, but it is typically reserved for **refractory status epilepticus** or as a long-term maintenance drug.
- It does not have the rapid onset of action required for initial management of an acute, prolonged seizure.
*Intravenous administration of fosphenytoin*
- **Fosphenytoin** is an antiepileptic drug often used for **refractory status epilepticus** after benzodiazepines have failed.
- It is not the first-line medication for the initial management of an acute seizure of this duration.
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