All practice questions

A cardiologist is invited to serve as a guest speaker at a regional continuing medical education (CME) conference focused on the management of heart failure. A pharmaceutical company that manufactures a newly approved heart failure medication offers to directly cover the physician's airfare, hotel accommodations, and registration fees for the conference. Additionally, the company representative provides a deck of presentation slides summarizing recent clinical trials of their drug, suggesting the physician use them during the lecture to "save preparation time." Based on the ethical guidelines regarding conflicts of interest and industry relations, which of the following is the most appropriate course of action for the cardiologist?

Match each clinical research scenario or action to the corresponding ethical concept or regulatory mechanism.

An attending general surgeon is served with a malpractice lawsuit by a former patient. One year prior, the patient underwent an elective laparoscopic cholecystectomy for biliary colic. According to the operative report, the surgeon unintentionally created a 2-millimeter serosal tear on the duodenum during gallbladder retraction. The surgeon identified the tear immediately, placed a single interrupted suture to repair it, and completed the procedure without further issues. The patient was informed of the event upon awakening. Medical records confirm the patient had an entirely unremarkable postoperative course, required no additional interventions, and returned to work five days later. The lawsuit alleges medical negligence due to the duodenal injury. Which of the following is the most accurate legal justification for the anticipated dismissal of this lawsuit?

A 42-year-old man undergoes an emergent exploratory laparotomy for a perforated viscus. Forty-eight hours postoperatively, he develops severe abdominal pain, fever, and worsening tachycardia. A computed tomography scan of the abdomen reveals a radiopaque marker consistent with a retained surgical sponge. The patient is currently sedated, intubated, and lacks decision-making capacity due to his critical condition. His sister, who is his legally appointed healthcare proxy via an advance directive, is at his bedside. His estranged wife has also arrived at the hospital and demands to make his medical decisions moving forward. The hospital risk management team convenes to discuss the medical error and the impending need for a second operation. Which of the following statements regarding the legal, ethical, and administrative management of this case are correct? (Select all that apply)

A 38-year-old man is being treated by a primary care physician for generalized anxiety disorder and chronic back pain. The patient is currently the defendant in a civil lawsuit regarding a motor vehicle collision. The physician receives a subpoena duces tecum signed by the plaintiff's attorney, requesting the patient's complete medical records. The physician contacts the patient, who explicitly refuses to authorize the release of any medical information. Which of the following is the most appropriate next step for the physician?

A 45-year-old man is brought to the emergency department by his wife due to acute-onset confusion, slurred speech, and an unsteady gait. His symptoms began earlier in the day and have progressively worsened. The patient has a history of severe Crohn's disease that necessitated multiple extensive small bowel resections three years ago, leaving him with short bowel syndrome. He does not consume alcohol and has no history of substance use. His temperature is 37.1°C (98.8°F), blood pressure is 110/70 mm Hg, heart rate is 88/min, and respiratory rate is 22/min. Physical examination reveals a confused man with an ataxic gait. His lungs are clear to auscultation. The abdomen is soft with well-healed surgical scars.

Laboratory studies show:

Arterial blood gas analysis on room air:

Which of the following best describes the primary underlying mechanism for this patient's current condition?

A 22-year-old woman with a history of type 1 diabetes mellitus is admitted to the intensive care unit with a two-day history of high fever, productive cough, and progressive lethargy. She has been unable to tolerate oral intake and missed her last four doses of insulin. On arrival, her temperature is $38.9^\circ\text{C}$ ($102^\circ\text{F}$), pulse is $132\text{/min}$, respiratory rate is $36\text{/min}$, and blood pressure is $88/54\text{ mm Hg}$. Oxygen saturation is $89\%$ on ambient air. Physical examination reveals deep, rapid breathing and bronchial breath sounds with crackles in the right lower lung field. Laboratory studies show a serum glucose of $510\text{ mg/dL}$, sodium of $134\text{ mEq/L}$, potassium of $4.9\text{ mEq/L}$, chloride of $98\text{ mEq/L}$, and bicarbonate of $10\text{ mEq/L}$. A chest radiograph confirms a right lower lobe consolidation. The patient is resuscitated with intravenous normal saline, started on a continuous insulin infusion, and administered intravenous ceftriaxone and azithromycin. Two hours later, her respiratory effort wanes and she becomes severely hypoxemic, necessitating endotracheal intubation. She is placed on volume assist-control mechanical ventilation with a tidal volume of $400\text{ mL}$, a respiratory rate of $14\text{/min}$, $FiO_2$ of $0.70$, and positive end-expiratory pressure (PEEP) of $5\text{ cm }H_2O$. Thirty minutes later, arterial blood gas analysis reveals:

$pH$: $7.15$
$PaCO_2$: $38\text{ mm Hg}$
$PaO_2$: $72\text{ mm Hg}$
$HCO_3^-$: $10\text{ mEq/L}$

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

A $68$-year-old woman arrives at the urgent care clinic reporting severe, progressively worsening difficulty breathing over the last $48$ hours. She notes that she has been waking up gasping for air in the middle of the night and now requires sleeping in her recliner to breathe comfortably. Her past medical history includes long-standing high blood pressure and diet-controlled type $2$ diabetes mellitus. She smoked cigarettes for $30$ years but quit a decade ago. Vital signs show a blood pressure of $162/96$ mm Hg, heart rate of $105$/min, and respiratory rate of $24$/min. Pulse oximetry indicates $92\%$ oxygen saturation on ambient air. Physical examination demonstrates noticeable distension of the neck veins while sitting upright. Lung auscultation reveals bilateral crackles at the bases. Cardiac auscultation detects an extra low-pitched sound occurring just after the second heart sound. Moderate pitting edema is present in both lower legs. Which of the following is the most appropriate initial pharmacological intervention to relieve this patient's respiratory distress?

A 34-year-old woman with no significant past medical history is evaluated in the clinic for a 6-month history of progressively worsening exertional dyspnea and fatigue. She has no cough, wheezing, orthopnea, or leg swelling. She does not smoke. Vital signs are within normal limits. Physical examination reveals a prominent right ventricular heave, a loud pulmonic component of the second heart sound (P2), and a faint holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. The lungs are clear to auscultation bilaterally. Electrocardiogram shows right axis deviation and right ventricular hypertrophy. Suspecting a primary pulmonary vascular disorder, the physician plans a comprehensive diagnostic workup.

Arrange the following diagnostic and management steps in the correct chronological sequence according to consensus guidelines for unexplained pulmonary hypertension, moving from initial screening to definitive management:

Match the following classic physical examination auscultation findings with the most likely underlying valvular pathology.

A $34$-year-old primigravida at $37$ weeks gestation is evaluated in the obstetric triage unit for worsening difficulty breathing over the past week. She states that she becomes excessively winded when walking up a single flight of stairs and has recently started using three pillows to sleep comfortably at night. She has a past medical history of mild persistent asthma, for which she occasionally uses an inhaled corticosteroid. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $118/78\text{ mmHg}$, pulse of $110/\text{min}$, and respiratory rate of $22/\text{min}$. Pulse oximetry is $94\%$ on room air. Physical examination reveals prominent distension of the neck veins while sitting at a $45$-degree incline. Chest auscultation reveals fine crackles at the bilateral lung bases. Cardiac auscultation reveals a regular tachycardia and an extra, low-pitched sound in early diastole. There is $2+$ pitting edema extending to the mid-shins bilaterally. Which of the following is the most appropriate next step in patient care?

Match each of the following classic arterial pulse abnormalities with the cardiovascular pathology most commonly associated with its presentation.

A 55-year-old male comes to the outpatient clinic reporting a 3-week history of swelling in both of his ankles. He mentions that his shoes feel uncomfortably tight by the end of the day. One month ago, he was diagnosed with primary hypertension and was started on amlodipine monotherapy. He denies any difficulty breathing, waking up at night gasping for air, chest discomfort, or recent travel. Vital signs are within normal limits, with a blood pressure of 126/80 mm Hg. Physical examination reveals 2+ pitting edema over the bilateral medial malleoli. The overlying skin is intact, with no erythema, warmth, or tenderness. Jugular venous pressure is 6 cm H2O. Lungs are clear to auscultation bilaterally, and cardiac auscultation reveals a regular rate and rhythm with no extra heart sounds. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old man is brought to the emergency department by his wife due to a 24-hour history of high fever, severe headache, and progressively worsening confusion. On physical examination, his temperature is 39.2°C (102.6°F), blood pressure is 130/80 mm Hg, and heart rate is 110/min. He has marked nuchal rigidity. Neurologic examination reveals a lethargic patient who only opens his eyes to painful stimuli. He demonstrates mild left-sided hemiparesis. Arrange the following steps in the most appropriate chronological sequence for the initial management of this patient.

A 62-year-old man presents to the clinic with a three-week history of a nonproductive cough and progressively worsening shortness of breath. He reports that his breathing becomes particularly difficult when he lies down to sleep at night, forcing him to prop himself up with three pillows. His medical history includes hypertension, osteoarthritis of the knees, and a 25-pack-year smoking history. Three weeks ago, he was evaluated for worsening knee pain and elevated blood pressure, at which time naproxen and amlodipine were added to his daily regimen. Temperature is 37.0°C (98.6°F), blood pressure is 152/92 mm Hg, pulse is 92/min, and respirations are 20/min. BMI is 31 kg/m². Lung auscultation reveals diffuse expiratory wheezing with no crackles. Cardiac examination shows a regular rhythm with normal S1 and S2; a faint, low-frequency sound is heard just after S2 at the cardiac apex. Trace bilateral pitting edema is present at the ankles. Which of the following is the most likely pathophysiologic mechanism underlying this patient's current respiratory symptoms?

Match the following pathophysiological states or clinical conditions with their most characteristic electrocardiogram (ECG) finding.

A 69-year-old woman is brought to the emergency department due to severe shortness of breath that awakened her from sleep 2 hours ago. She has a history of hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. Her current medications include amlodipine and metformin. Her temperature is 36.8°C (98.2°F), blood pressure is 172/98 mm Hg, pulse is 115/min, and respirations are 26/min. Pulse oximetry is 89% on room air. Physical examination reveals elevated jugular venous pressure. Lung auscultation demonstrates bilateral basilar crackles and diffuse expiratory wheezing. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. There is 1+ bilateral lower extremity pitting edema. Which of the following diagnostic findings is most likely to be present in this patient?

A $64$-year-old man is brought to the emergency department by ambulance due to the sudden onset of severe, "tearing" chest pain that radiates to his interscapular region. He has a history of poorly controlled hypertension. On arrival, he appears diaphoretic and in severe distress. His blood pressure is $210/115\text{ mmHg}$ in the right arm and $170/95\text{ mmHg}$ in the left arm. His heart rate is $115\text{/min}$. A portable chest radiograph reveals a widened mediastinum. An acute aortic dissection is highly suspected. Arrange the following next steps in the most appropriate chronological sequence for the initial management of this patient.

Match each of the following specific cardiomyopathies with its most characteristic echocardiographic finding.

A 71-year-old retired teacher with a 45-pack-year smoking history is brought to the emergency department at 2:00 AM by his spouse due to sudden, severe respiratory distress. The patient states he was awakened from sleep by a feeling of suffocation. His medical history includes essential hypertension and moderate chronic obstructive pulmonary disease, for which he uses a daily long-acting muscarinic antagonist. Vital signs show a temperature of 36.8°C (98.2°F), blood pressure of 182/105 mm Hg, heart rate of 115/min, and respiratory rate of 28/min. Pulse oximetry is 87% on room air. Physical examination reveals a patient in obvious distress, using accessory muscles of respiration. The jugular venous pressure is estimated at 11 cm H2O, and sustained manual compression of the mid-abdomen results in a persistent 4 cm elevation of the jugular venous column. Pulmonary auscultation reveals widespread, high-pitched expiratory wheezes without any audible crackles. Cardiac examination is notable for a regular tachycardia and a low-frequency sound occurring shortly after the second heart sound, best heard over the fifth intercostal space at the midclavicular line. A portable chest radiograph displays hyperlucent lung fields with flattened diaphragms, accompanied by vascular redistribution to the upper lung zones and distinct bronchial wall thickening. Based on the clinical presentation, which of the following sets of hemodynamic findings is most likely present in this patient?