NP Case Studies & Practical Application 5 — Questions and Answers
Question 1: A 78-year-old woman is brought by family for confusion over 2 days. She lives alone, has multiple chronic conditions, and takes 12 medications. Vitals are normal. Urinalysis shows 5–10 WBCs/hpf and bacteria. What is the most appropriate initial approach?
- Start ciprofloxacin immediately for urinary tract infection
- Conduct a comprehensive delirium workup before attributing confusion to bacteriuria (Correct answer)
- Obtain urine culture and start empiric cefazolin IV
- Increase her home aide hours and reassess in 72 hours
Correct answer: Conduct a comprehensive delirium workup before attributing confusion to bacteriuria
Asymptomatic bacteriuria is common in elderly women and does not explain delirium; a thorough evaluation for other causes (medications, metabolic, CNS) must occur.
Question 2: A 30-year-old man with HIV (CD4 count 45 cells/μL, not on ART) presents with headache, fever, and neck stiffness for 5 days. CSF analysis shows increased opening pressure, low glucose, and India ink stain reveals encapsulated yeast. What is the treatment of choice for induction?
- Fluconazole 400 mg daily for 8 weeks
- Liposomal amphotericin B plus flucytosine for 2 weeks (Correct answer)
- IV acyclovir 10 mg/kg every 8 hours
- Voriconazole 200 mg twice daily
Correct answer: Liposomal amphotericin B plus flucytosine for 2 weeks
Cryptococcal meningitis induction therapy in HIV is liposomal amphotericin B plus flucytosine for 2 weeks, followed by fluconazole consolidation.
Question 3: A 42-year-old woman presents with a 6-month history of episodic severe headache, diaphoresis, palpitations, and hypertension with BP reaching 210/120 during episodes. Between episodes she is normotensive. Which test is most appropriate?
- Serum aldosterone-to-renin ratio
- 24-hour urine fractionated metanephrines and catecholamines (Correct answer)
- Overnight dexamethasone suppression test
- Renal artery Doppler ultrasound
Correct answer: 24-hour urine fractionated metanephrines and catecholamines
Episodic hypertension with the classic triad of headache, diaphoresis, and palpitations is highly suspicious for pheochromocytoma; 24-hour urine metanephrines is the preferred screening test.
Question 4: A 16-year-old girl is brought in by her mother for amenorrhea for 8 months and a 20-lb weight loss. BMI is 16.5 kg/m². She exercises 3 hours daily and states she 'feels fat.' Vital signs reveal HR 48 bpm and BP 88/56 mmHg. What is the priority intervention?
- Refer to outpatient nutritional counseling only
- Assess medical stability and arrange inpatient medical stabilization if criteria are met (Correct answer)
- Prescribe an SSRI for the underlying depression
- Order an ECG and discharge with eating disorder resources
Correct answer: Assess medical stability and arrange inpatient medical stabilization if criteria are met
Bradycardia and hypotension in a patient with anorexia nervosa indicate hemodynamic instability requiring inpatient medical stabilization before any outpatient therapy.
Question 5: A 65-year-old man with a history of MI and HFrEF (EF 30%) presents with increasing dyspnea and bilateral leg edema. His medications include carvedilol, lisinopril, and furosemide 40 mg daily. BNP is 920 pg/mL and creatinine is 1.1 mg/dL. What medication addition has the strongest mortality benefit in this patient?
- Digoxin 0.125 mg daily
- Spironolactone 25 mg daily (Correct answer)
- Isosorbide dinitrate/hydralazine combination
- Ivabradine if HR >70 bpm on max beta-blocker
Correct answer: Spironolactone 25 mg daily
Aldosterone antagonists (spironolactone/eplerenone) reduce mortality by ~30% in symptomatic HFrEF and are guideline-directed with strong evidence from the RALES and EMPHASIS-HF trials.
Question 6: A 38-year-old woman presents with 4 months of fatigue, constipation, cold intolerance, weight gain of 12 lbs, and dry skin. TSH is 18 mIU/L and free T4 is 0.6 ng/dL. What is the treatment goal?
- Normalize TSH to 0.1–0.5 mIU/L for symptom relief
- Achieve TSH within the reference range (0.5–4.5 mIU/L) on levothyroxine (Correct answer)
- Maintain TSH at 5–10 mIU/L to avoid over-replacement
- Prescribe T3 supplementation as monotherapy
Correct answer: Achieve TSH within the reference range (0.5–4.5 mIU/L) on levothyroxine
The treatment goal for hypothyroidism is a TSH within the normal reference range (0.5–4.5 mIU/L) on the lowest effective levothyroxine dose.
Question 7: A 52-year-old man with alcohol use disorder presents 3 days after his last drink with agitation, tremors, diaphoresis, and auditory hallucinations. Vitals: HR 118, BP 162/94, T 38.1°C. CIWA-Ar score is 22. What is the first-line treatment?
- Haloperidol IM for hallucinations and lorazepam PRN for tremors
- Symptom-triggered benzodiazepine therapy (diazepam or lorazepam) (Correct answer)
- Propranolol to control heart rate and blood pressure
- Supportive care with IV fluids and thiamine only
Correct answer: Symptom-triggered benzodiazepine therapy (diazepam or lorazepam)
Moderate-to-severe alcohol withdrawal (CIWA-Ar >15) is treated with symptom-triggered benzodiazepines, which are the most effective agents for preventing seizures and delirium tremens.
NP Case Studies & Practical Application 5
A 78-year-old woman is brought by family for confusion over 2 days.
She lives alone, has multiple chronic conditions, and takes 12 medications.
Vitals are normal.
Urinalysis shows 5–10 WBCs/hpf and bacteria.
What is the most appropriate initial approach?