All practice questions

While recovering on postoperative day 6 following a coronary artery bypass graft, a 62-year-old male develops acute-onset right calf pain. His postoperative course had been previously uncomplicated, and he has been receiving subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis.

Vital signs show a temperature of 37.1°C (98.8°F), heart rate of 94/min, blood pressure of 132/82 mm Hg, and respiratory rate of 16/min. Physical examination reveals a swollen, tender, and mildly erythematous right calf. The right calf circumference is 4 cm greater than the left.

Laboratory studies are obtained and reveal the following:

A review of the patient's medical record shows a baseline platelet count of 220,000/mm³ on the day of admission.

Which of the following is the most appropriate next step in management of this patient?

A $72$-year-old man is brought to the emergency department due to sudden-onset, severe shortness of breath that awoke him from sleep $2$ hours ago. The patient has a history of hypertension, coronary artery disease, and a $40$-pack-year smoking history. He reports no recent fever, chills, or changes in sputum production. His blood pressure is $180/100$ mm Hg, pulse is $118$/min, respirations are $28$/min, and oxygen saturation is $86\%$ on room air. Physical examination reveals an upright, diaphoretic patient using accessory muscles of respiration. Jugular venous distention is present $9$ cm above the sternal angle. Lung auscultation demonstrates a prolonged expiratory phase with loud, diffuse bilateral wheezes and no distinct crackles. A third heart sound (S $3$) is heard at the apex. Bilateral $2+$ pitting edema is noted in the lower extremities. The patient is placed on noninvasive positive pressure ventilation, which improves his oxygen saturation to $94\%$. Arterial blood gas analysis before positive pressure ventilation showed:

pH: $7.25$
PaCO $_2$: $60$ mm Hg
PaO $_2$: $52$ mm Hg
HCO $_3^-$: $26$ mEq/L

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 reporting severe, throbbing pain in his right big toe that awoke him from sleep last night. He states the pain is so intense that even the weight of a bedsheet is intolerable. He has no recent history of trauma or previous similar episodes. His medical history is notable for essential hypertension, for which he takes hydrochlorothiazide. Vital signs are within normal limits. Physical examination reveals a markedly swollen, erythematous, warm, and exquisitely tender right first metatarsophalangeal joint. Which of the following is the most appropriate initial medication for this patient's acute condition?

A $44$-year-old man is evaluated on the medical unit on the third day of hospitalization for a right thigh infection. He initially presented with an expanding, painful, fluctuant mass on his anterior thigh accompanied by a $10$-cm area of surrounding erythema. Upon admission, he had a temperature of $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$) and a leukocyte count of $16,000/\text{mm}^3$. An incision and drainage were performed, yielding $35\text{ mL}$ of purulent material. He was started on empiric intravenous vancomycin and piperacillin-tazobactam.

Today, the patient is afebrile, and his pain is well-controlled. The erythema has receded significantly, and his leukocyte count is $7,500/\text{mm}^3$. The patient is tolerating a regular diet. The purulent fluid culture demonstrates heavy growth of *Staphylococcus aureus*. The isolate has the following susceptibility profile:

- Cefazolin: Susceptible
- Clindamycin: Susceptible
- Oxacillin: Susceptible
- Penicillin: Resistant
- Trimethoprim-sulfamethoxazole: Susceptible
- Vancomycin: Susceptible

Which of the following is the most appropriate next step in this patient's pharmacological management?

A 71-year-old female resident of a long-term care facility was admitted to the hospital $4$ days ago with a temperature of $39.0^{\circ}\text{C}$ ($102.2^{\circ}\text{F}$), rigors, and severe left-sided flank pain. Initial evaluation revealed marked left costovertebral angle tenderness. Laboratory testing demonstrated a leukocyte count of $15,200/\mu\text{L}$ with a left shift. Urinalysis was strongly positive for leukocyte esterase, nitrites, and numerous bacteria. The patient was started on empiric intravenous meropenem and intravenous fluids.

Today (hospital day 4), the patient is hemodynamically stable, has been afebrile for the past $48$ hours, and her flank pain has significantly improved. She is eating a normal diet and is eager to return to her facility. Blood cultures drawn on admission remain negative. The admission urine culture grew $>100,000$ colony-forming units/mL of *Escherichia coli*. Susceptibility testing results for the isolate are as follows:

Which of the following is the most appropriate next step in pharmacotherapy for this patient?

A pediatric clinic is reviewing the immunization records of several patients with specific underlying conditions or clinical circumstances. Match each pediatric patient with the specific vaccine or immunoprophylaxis that is most appropriately indicated for their ongoing care.

A $5$-month-old male infant is brought to the pediatric clinic by his parents for a well-child visit. The parents report that he is a "very quiet baby" who sleeps most of the day, but they are concerned because he frequently strains to pass hard, pellet-like stools. He is not yet rolling over and rarely coos. He was born at $39$ weeks gestation via uncomplicated vaginal delivery. The state's newborn screening program primarily measures thyroid-stimulating hormone (TSH) levels, which were reported as normal. On physical examination, his length is at the $5$ th percentile and weight is at the $25$ th percentile. His heart rate is $90$/min and temperature is $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$). He exhibits generalized hypotonia and a stretched penile length of $1.5 \text{ cm}$ (normal $> 2.5 \text{ cm}$). Laboratory evaluation reveals:

Serum thyroid-stimulating hormone (TSH): $2.1 \mu\text{U/mL}$ (normal: $0.5$–$5.0 \mu\text{U/mL}$)
Serum free thyroxine (T4): $0.4 \text{ ng/dL}$ (normal: $0.9$–$2.2 \text{ ng/dL}$)
Serum glucose: $52 \text{ mg/dL}$

Which of the following is the most likely cause of this infant's condition?

A medical student is preparing for a developmental pediatrics rotation and reviewing expected milestone acquisitions. Understanding the timeline of language development is critical for early identification of developmental delays. Arrange the following expressive language milestones in the typical chronological order in which they emerge in a healthy, neurotypical child, from earliest to latest.

A 12-month-old boy is brought to the office for a routine well-child visit. Three months ago, he was hospitalized for a 5-day history of high fever, polymorphic rash, bilateral conjunctival injection, and cervical lymphadenopathy. He was diagnosed with Kawasaki disease and treated successfully with high-dose intravenous immunoglobulin (IVIG) and aspirin. He is currently taking no medications. The mother expresses concern that her son is not yet walking independently and only says "mama" and "dada" specifically. He pulls to stand, cruises along furniture, uses a neat pincer grasp, and points to objects. His length, weight, and head circumference are at the 50th percentile. Physical examination is normal. His immunization record shows he received all recommended vaccines at ages 2, 4, and 6 months. Which of the following is the most appropriate management for this patient today?

A 31-year-old man with a known history of intravenous drug use presents to the emergency department complaining of high fever, severe chills, and generalized malaise for the past three days. Vital signs demonstrate a temperature of $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure of $112/68\text{ mmHg}$, heart rate of $118/\text{min}$, and respiratory rate of $20/\text{min}$. Physical examination reveals a new blowing holosystolic murmur that is loudest at the left lower sternal border, along with pinpoint, non-tender, erythematous macules on his palms. Arrange the following management steps in the most appropriate chronological order for this patient.

Match each clinical presentation of an opportunistic infection in a patient with advanced HIV to its most appropriate first-line targeted antimicrobial therapy.

Match each highly specific clinical scenario of an infectious disease with the most appropriate targeted pharmacologic management or intervention step, considering the patient's unique contraindications and risk factors.

A 28-year-old woman visits her primary care clinic due to a spreading rash on her right leg. She first noticed a small red bump four days ago, which has since expanded. The patient returned from a week-long camping trip in Connecticut ten days ago. She reports mild fatigue and muscle aches but denies fever, joint swelling, neck stiffness, or facial asymmetry. Her vital signs are within normal limits. Physical examination reveals a 9-cm erythematous annular plaque with central clearing on the right posterior calf. The lesion is flat, non-tender, and non-pruritic. Neurological and cardiovascular examinations are unremarkable. Which of the following is the most appropriate next step in management?

A $41$-year-old woman comes to the clinic for evaluation of worsening fatigue, generalized weakness, and a $3$-kg weight gain over the past $5$ months. She also reports increased sensitivity to cold and irregular menstrual cycles. She takes no daily medications. Her blood pressure is $110/70$ mm Hg, and her pulse is $58$/min. Physical examination reveals dry skin and delayed relaxation of the deep tendon reflexes. Laboratory testing shows a thyroid-stimulating hormone (TSH) level of $0.15 \ \mu\text{U/mL}$ (normal: $0.4-4.0 \ \mu\text{U/mL}$) and a free thyroxine (T4) level of $0.6 \text{ ng/dL}$ (normal: $0.9-1.7 \text{ ng/dL}$). Which of the following is the most likely diagnosis?

A 65-year-old man is brought to the emergency department by his wife due to worsening confusion, weakness, and fatigue over the past 24 hours. He has a history of a nonfunctioning pituitary macroadenoma treated with transsphenoidal resection and radiation therapy 3 years ago, chronic obstructive pulmonary disease (COPD), and heart failure with preserved ejection fraction. Four days ago, he was diagnosed with a mild COPD exacerbation at an urgent care clinic and was prescribed a 5-day course of azithromycin. Today, his temperature is 36.1°C (97.0°F), blood pressure is 88/54 mm Hg, pulse is 110/min, and respirations are 24/min. Pulse oximetry is 93% on room air. Physical examination shows a lethargic man who follows simple commands. Jugular venous pressure is 6 cm $H_2O$. Chest auscultation reveals distant breath sounds and scattered end-expiratory wheezes unchanged from his baseline. Heart sounds are normal. The extremities are cool without edema. Laboratory studies show:

Sodium: 131 mEq/L
Potassium: 3.9 mEq/L
Chloride: 98 mEq/L
Bicarbonate: 14 mEq/L
Blood urea nitrogen: 42 mg/dL
Creatinine: 1.8 mg/dL
Glucose: 62 mg/dL
Thyroid-stimulating hormone: 0.2 µU/mL (Normal: 0.4-4.0 µU/mL)
Free T4: 0.6 ng/dL (Normal: 0.9-1.7 ng/dL)

Arterial blood gas analysis on room air reveals:
pH: 7.31
PaCO2: 29 mm Hg
PaO2: 78 mm Hg

Which of the following is the most appropriate next step in management?

A 1-week-old male newborn is brought to the pediatric clinic for his initial newborn follow-up visit. He was born at 39 weeks gestation via an uncomplicated spontaneous vaginal delivery to a 28-year-old primigravida. His birth weight was 3.4 kg (7 lb 8 oz). Current vital signs include a temperature of 36.8°C (98.2°F), heart rate of 140/min, and respiratory rate of 40/min. Physical examination reveals a healthy, vigorous neonate with normal muscle tone, a flat anterior fontanelle, and symmetric primitive reflexes. He received the first dose of the hepatitis B vaccine at birth and is feeding well on demand. His first-time parents are eager to understand what to expect regarding his neurodevelopmental progress over the coming years.

Arrange the following developmental milestone clusters in the chronological order of their expected emergence in a typically developing healthy child.

During a January night shift, emergency medical services transport a 64-year-old woman to the resuscitation bay due to a progressive decline in consciousness over the past two days. According to her daughter, the patient recently had a mild upper respiratory tract infection but has not been febrile. Her medical history includes diet-controlled type 2 diabetes mellitus and a hospitalization one year ago for 'fluid in the lungs.'

Vital signs reveal a temperature of 34.5°C (94.1°F), blood pressure of 90/60 mm Hg, heart rate of 48/min, and respiratory rate of 10/min. Pulse oximetry shows 89% on room air.

Physical examination demonstrates a somnolent patient with generalized non-pitting edema, a puffy face, and macroglossia. Deep tendon reflexes exhibit markedly delayed relaxation. Auscultation reveals diminished breath sounds at both lung bases without wheezes or crackles.

Laboratory analysis:
Sodium: 128 mEq/L
Potassium: 4.1 mEq/L
Chloride: 98 mEq/L
Bicarbonate: 28 mEq/L
Blood urea nitrogen: 25 mg/dL
Creatinine: 1.1 mg/dL
Thyroid-stimulating hormone (TSH): 1.1 µU/mL (normal: 0.5–5.0 µU/mL)
Free thyroxine (T4): 0.3 ng/dL (normal: 0.9–1.7 ng/dL)

Arterial blood gas (room air):
pH: 7.31
pCO2: 56 mm Hg
pO2: 58 mm Hg

An electrocardiogram shows sinus bradycardia with low voltage complexes. Chest radiography reveals mild cardiomegaly and small bilateral pleural effusions without focal consolidation.

Which of the following is the most appropriate initial management for this patient?

A hematology consultation service is reviewing the clinical data and coagulation profiles of five distinct adult patients. Based on the patterns of standard coagulation testing (PT, aPTT), mixing studies, and clinical presentation, match each patient's profile to the most accurate underlying diagnosis.

A 68-year-old man is evaluated in the hospital for sudden-onset, severe right knee pain. He is currently on postoperative day 6 following an uncomplicated robotic-assisted prostatectomy for prostate cancer. He reports that the pain began abruptly overnight and is so severe that he cannot tolerate the weight of his bedsheet on his leg. His medical history is significant for hypertension, type 2 diabetes mellitus, and chronic kidney disease stage 3. His temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $138/85\text{ mmHg}$, and pulse is $98/\text{min}$. Physical examination reveals a markedly swollen, erythematous, and warm right knee. There is a palpable effusion, and both active and passive range of motion are severely limited by pain. The surgical incisions in the abdomen are clean, dry, and intact with no surrounding erythema. Which of the following is the most appropriate next step in management of this patient's joint pain?

Evaluate the following four patient presentations encountered in the acute internal medicine setting. Match each clinical vignette describing a toxicological emergency with the most appropriate definitive pharmacologic intervention.