All practice questions

A 42-year-old woman with a 3-year history of diffuse cutaneous systemic sclerosis comes to the emergency department due to a severe headache and blurred vision that began 24 hours ago. Her temperature is 37.0°C (98.6°F), blood pressure is 218/116 mm Hg, and pulse is 92/min. Physical examination shows tight, thickened skin over the face, trunk, and extremities. Laboratory studies show a serum creatinine of 2.9 mg/dL (baseline 0.9 mg/dL) and a hemoglobin of 10.2 g/dL. A peripheral blood smear reveals numerous schistocytes. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man comes to the emergency department complaining of progressive shortness of breath and an increasingly productive cough over the last 3 days. He notes his sputum has changed from clear to thick and yellowish-green. His medical history is significant for chronic obstructive pulmonary disease (COPD) and a 45-pack-year smoking history. Temperature is 37.6°C (99.7°F), blood pressure is 138/86 mmHg, pulse is 92/min, and respiratory rate is 22/min. Oxygen saturation is 89% on room air. Physical examination reveals a barrel-shaped chest with diffuse bilateral expiratory wheezing and a prolonged expiratory phase. Jugular venous pressure is normal, and there is no lower extremity edema. A bedside chest radiograph demonstrates hyperinflated lungs with flattened diaphragms, but no focal consolidations, pleural effusions, or cardiomegaly. Which of the following is the most appropriate next step in management?

A $54$-year-old man undergoing induction chemotherapy for acute myeloid leukemia presents to the emergency department with a new-onset fever of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$) and chills. He has an indwelling central venous catheter. His blood pressure is $105/65 \text{ mm Hg}$, heart rate is $112/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals no obvious source of infection, and the catheter site appears clean without erythema or fluctuance. Laboratory studies demonstrate an absolute neutrophil count of $200/\mu\text{L}$. Arrange the following management steps in the most appropriate chronological sequence for this patient.

As part of an introductory hematopathology module, a medical trainee is asked to correlate microscopic cellular abnormalities with their corresponding disease states. Match each classic peripheral blood smear description with the diagnosis it most strongly suggests.

A $35$-year-old man presents to the emergency department with a $3$-day history of increasing fatigue, spontaneous gum bleeding, and a diffuse petechial rash. He has no significant past medical history and takes no medications. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), heart rate $105/\text{min}$, blood pressure $110/70\text{ mmHg}$, and respiratory rate $18/\text{min}$. Physical examination reveals pale conjunctivae, continuous oozing from the gingival margins, diffuse petechiae on the lower extremities, and large ecchymoses on the trunk. There is no hepatosplenomegaly or lymphadenopathy.

Laboratory results are as follows:

A peripheral blood smear reveals numerous large, atypical mononuclear cells with abundant cytoplasm containing multiple primary granules and prominent needle-like cytoplasmic inclusions.

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

A 4-year-old boy is brought to the pediatric clinic in late September for a well-child visit. He was diagnosed with moderate-to-severe Crohn disease 6 months ago. His current medications include infliximab, a tumor necrosis factor-alpha (TNF-α) inhibitor, which has led to clinical remission and appropriate weight gain. He has no other medical conditions. His immunizations were up to date until his 18-month visit. He is now due for his routine preschool vaccinations, and the parents also request the seasonal influenza vaccine. His vital signs are temperature 36.8°C (98.2°F), heart rate 98/min, and respiratory rate 20/min. Physical examination is unremarkable.

Which of the following is the most appropriate immunization plan for this patient today?

A 53-year-old woman is brought to the emergency department by her husband due to a severe headache, blurred vision, and progressive confusion over the past 24 hours. Her past medical history is significant for diffuse cutaneous systemic sclerosis diagnosed three years ago. Two weeks ago, she was started on oral prednisone for worsening joint pain and skin tightness. Her temperature is 37.1°C (98.8°F), blood pressure is 225/115 mmHg, and pulse is 102/min. Physical examination shows thickened, tight skin over her face, forearms, and chest. Neurological examination reveals a confused patient but is negative for focal motor or sensory deficits. Fundoscopy demonstrates bilateral flame-shaped hemorrhages and papilledema. Laboratory studies show:

A peripheral blood smear demonstrates 3-5 schistocytes per high-power field. Her baseline creatinine one month ago was 0.8 mg/dL. Which of the following is the most appropriate next step in the pharmacologic management of this patient's condition?

A physician is evaluating a hospitalized patient with chronic kidney disease who has developed anuria and profound muscle weakness over the past twelve hours. An electrocardiogram demonstrates prolonged PR intervals, widened QRS complexes, and tall, peaked T waves. A point-of-care basic metabolic panel reveals a serum potassium level of $7.4$ mEq/L. Arrange the following therapeutic interventions in the most appropriate chronological order of administration for this patient's acute management.

An occupational health physician evaluates a $49$-year-old man who reports a progressive decline in energy levels, persistent chills, and lower extremity swelling over the past six months. The patient mentions he struggles to stay awake during daytime meetings and feels short of breath when climbing the stairs to his office. He takes no daily medications. His temperature is $36.1^{\circ}\text{C}$ ($97.0^{\circ}\text{F}$), blood pressure is $105/65\text{ mm Hg}$, pulse is $52/\text{min}$, and respiratory rate is $12/\text{min}$. Physical examination demonstrates non-pitting edema of the bilateral lower extremities, coarse hair, and delayed relaxation of deep tendon reflexes. Lung fields are clear to auscultation. Laboratory results show a serum free T4 level of $0.3\text{ ng/dL}$ (Normal: $0.9-1.7\text{ ng/dL}$) and a thyroid-stimulating hormone (TSH) level of $1.8\text{ mIU/L}$ (Normal: $0.5-5.0\text{ mIU/L}$). Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old woman is evaluated in the preoperative clinic prior to an elective right total knee arthroplasty. Her past medical history is notable for osteoarthritis and well-controlled hypertension. The patient reports feeling well and specifically denies any dysuria, urinary frequency, suprapubic pain, or fever. Her vital signs are within normal limits. As part of her preoperative workup, a urinalysis is obtained which demonstrates 15 white blood cells per high-power field and is positive for leukocyte esterase and nitrites. A subsequent urine culture grows >$10^5$ colony-forming units/mL of *Escherichia coli*. Susceptibility testing shows the organism is sensitive to nitrofurantoin, trimethoprim-sulfamethoxazole, ciprofloxacin, and ceftriaxone. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man with a history of ischemic cardiomyopathy (left ventricular ejection fraction 35%), severe chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus is evaluated in the intensive care unit. He was admitted 3 days ago for urosepsis after presenting with fever, hypotension, and altered mental status. On admission, he received 4 liters of intravenous normal saline and was started on empiric intravenous vancomycin and cefepime.

Blood cultures from admission grew *Escherichia coli* at 24 hours. Today, sensitivities resulted showing the organism is susceptible to ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole, but resistant to ampicillin.

The patient is now afebrile and his blood pressure has stabilized off vasopressors. However, the nurse reports that he has developed worsening dyspnea over the last 12 hours.

Vital signs are:
Blood pressure: $128/78 \text{ mmHg}$
Heart rate: $102/\text{min}$
Respiratory rate: $26/\text{min}$
$SpO_2$: $89\%$ on room air

Physical examination reveals an elevated jugular venous pressure of $11 \text{ cm } H_2O$. Lung auscultation demonstrates bibasilar crackles and scattered expiratory wheezes. There is 2+ bilateral pitting lower extremity edema.

Arterial blood gas (room air):
pH: $7.27$
$pCO_2$: $26 \text{ mmHg}$
$pO_2$: $64 \text{ mmHg}$

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

A 55-year-old man is admitted to the hospital after a lymph node biopsy confirmed the diagnosis of a highly aggressive non-Hodgkin lymphoma. He is scheduled to receive his first cycle of multi-agent chemotherapy in $24$ hours. He currently has no acute complaints. Vital signs are within normal limits. Laboratory studies reveal the following:

Which of the following is the most appropriate next step in management to prevent acute renal complications in this patient?

A $32$-year-old man comes to the clinic for routine sexually transmitted infection screening. He is currently asymptomatic and has no history of genital ulcers, diffuse rashes, or neurologic symptoms. He reports having unprotected intercourse with a new male sexual partner $2$ months ago. He has no known prior history of syphilis or other sexually transmitted infections. Vital signs are within normal limits. Physical examination reveals no oral, genital, or perianal lesions, and no lymphadenopathy is appreciated. The clinic laboratory utilizes the reverse sequence algorithm for syphilis screening. The initial *Treponema pallidum* enzyme immunoassay (EIA) returns reactive. A reflex rapid plasma reagin (RPR) test is nonreactive. Which of the following is the most appropriate next step in management?

A 42-year-old woman is evaluated in the hospital on the fourth day of admission for acute severe pancreatitis. She has been receiving intravenous fluids via a right internal jugular central venous catheter placed on admission. Yesterday, her temperature briefly spiked to 38.3°C (100.9°F). One set of peripheral blood cultures and one set from the central venous catheter were obtained at that time. Today, she reports that her abdominal pain is improving. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, pulse is 82/min, and respirations are 14/min. Physical examination shows a clean central catheter insertion site with no surrounding erythema or induration. Laboratory studies show a leukocyte count of 9,200/mm³. The aerobic bottle of the peripheral blood culture set is growing coagulase-negative staphylococci after 24 hours of incubation. The anaerobic peripheral bottle and both bottles from the central catheter show no growth. Which of the following is the most appropriate next step in management?

An oncologist is called to evaluate a $58$-year-old man in the hospital who has a history of metastatic non-small cell lung cancer. The patient reports a $1$-week history of worsening, band-like thoracic back pain that is particularly severe when lying supine. Over the last $24$ hours, he has noticed progressive heaviness in both legs and has not voided urine since the previous evening. On neurologic examination, there is $3/5$ muscle strength in the lower extremities bilaterally, pronounced hyperreflexia at the patellae, and a sensory deficit to pinprick extending distally from the umbilicus. Arrange the following steps in the most appropriate chronological order for the management of this patient's current condition.

Match the following clinical scenarios of oncologic therapy and associated toxicities with the most appropriate pharmacological rescue or prophylactic agent.

A $22$-year-old woman is brought to the emergency department by her college roommate due to bizarre behavior over the past $4$ days. The roommate states that the patient has locked herself in her room, claims that hidden cameras are recording her thoughts, and frequently talks to people who are not present. She has no personal or family history of psychiatric illness. Over the past month, the patient has complained of severe fatigue, diffuse joint pain, and increased hair shedding. Her temperature is $37.9^{\circ}C$ ($100.2^{\circ}F$), blood pressure is $146/92$ mm Hg, and pulse is $98$/min. Physical examination reveals an erythematous, scaling rash across her cheeks and the bridge of her nose that spares the nasolabial folds. Painless ulcers are noted on the hard palate. The proximal interphalangeal and metacarpophalangeal joints are mildly swollen, warm, and tender to palpation bilaterally.

Which of the following is the most appropriate initial treatment targeting the underlying etiology of this patient's condition?

A 2-day-old male newborn is evaluated in the nursery for a new-onset skin rash. He was born at 39 weeks gestation via uncomplicated spontaneous vaginal delivery. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The infant has been breastfeeding well and has had normal bowel and bladder function. Temperature is 37.1 C (98.8 F), heart rate is 140/min, and respiratory rate is 40/min. Physical examination reveals multiple erythematous macules and papules with central 1- to 2-mm yellow-white pustules scattered across the trunk and proximal extremities. The palms and soles are spared. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?

A 2-month-old girl is brought to the clinic for her first well-child examination. She was born at 39 weeks gestation via spontaneous vaginal delivery. Her mother has a history of severe, refractory Crohn's disease, which has been managed with regular infusions of infliximab throughout the pregnancy, with the final dose administered at 36 weeks gestation. The infant's newborn screen was normal. She has been exclusively breastfed and is gaining weight well. On examination, the infant appears well. She smiles responsively, makes cooing sounds, and tracks the examiner's face past the midline. When placed in the prone position, she is able to lift her head to 45 degrees. The mother expresses concern that the infant is not yet reaching for objects or rolling over. Her tone and reflexes are normal. She previously received the Hepatitis B vaccine at birth. Which of the following is the most appropriate next step in management regarding her immunizations and development?

A 54-year-old woman is evaluated in the emergency department for a 24-hour history of severe headache, fever, and progressive confusion. Her temperature is 39.4°C (102.9°F), blood pressure is 110/68 mm Hg, and pulse is 114/min. On physical examination, the patient is lethargic and oriented to person only. Neck stiffness is elicited upon flexion. There are no focal neurologic deficits. Arrange the following management steps in the most appropriate chronological sequence for this patient.