All practice questions

An ambulatory care physician evaluates a 33-year-old woman who reports a one-month history of persistent fatigue and severe muscle weakness. She denies any recent illnesses, diarrhea, vomiting, or medication use. Her vital signs are within normal limits. Physical examination reveals diffusely decreased muscle strength in all extremities with diminished deep tendon reflexes.

Laboratory studies reveal the following:

Based on the laboratory data provided, what is this patient's urine anion gap (in mEq/L)?

A 50-year-old man visits his primary care provider due to worsening fatigue, sluggishness, and increased sensitivity to cold over the past 6 months. He has also noticed decreased libido and erectile dysfunction. His vital signs show a pulse of 54/min and blood pressure of 110/70 mm Hg. Physical examination reveals dry skin and delayed relaxation of the Achilles tendon reflexes. Visual field testing demonstrates decreased peripheral vision on the lateral sides of both eyes (bitemporal hemianopsia). Laboratory testing reveals a free thyroxine (T4) level of 0.4 ng/dL (normal: 0.9-1.7 ng/dL) and a thyroid-stimulating hormone (TSH) level of 1.1 µU/mL (normal: 0.5-5.0 µU/mL). Which of the following best explains this patient's thyroid function test results?

Match each classic laboratory profile to its most likely underlying pathophysiologic diagnosis.

A $68$-year-old man is evaluated in the intensive care unit on day $5$ of his admission. He was initially hospitalized for severe community-acquired pneumonia complicated by septic shock and acute respiratory distress syndrome. He remains intubated and mechanically ventilated, though vasopressor support was discontinued yesterday. His medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus. The patient's family confirms he had no known thyroid disease and was highly active prior to this illness. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse is $84/\text{min}$, and blood pressure is $118/72\text{ mmHg}$. Physical examination reveals a normal-appearing thyroid gland with no palpable masses. The patient is lethargic but opens his eyes to noxious stimuli while sedation is being weaned. Routine laboratory studies reveal the following:

TSH: $0.2\text{ \mu U/mL}$ (Normal: $0.4-4.0\text{ \mu U/mL}$)
Free T4: $0.7\text{ ng/dL}$ (Normal: $0.9-1.7\text{ ng/dL}$)
Total T3: $45\text{ ng/dL}$ (Normal: $80-200\text{ ng/dL}$)

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

Match each clinical presentation of infective endocarditis with the most appropriate targeted antimicrobial regimen based on current consensus guidelines.

A $45$-year-old man is hospitalized for community-acquired pneumonia. Ten minutes after starting his first dose of intravenous ceftriaxone, he develops sudden-onset diffuse urticaria, shortness of breath, and throat tightness. His temperature is $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $124/\text{min}$, and respiratory rate is $26/\text{min}$. Oxygen saturation is $90\%$ on room air. Examination reveals diffuse expiratory wheezing and facial angioedema. Arrange the following steps in the most appropriate chronological order for the acute management of this patient's condition.

A $44$-year-old woman is evaluated for a $6$-month history of progressive weight gain, new-onset facial hair growth, and easy bruising. Her blood pressure is $160/100$ mmHg. Physical examination reveals a rounded face, dorsocervical fat pad, prominent proximal muscle weakness, and wide, violaceous abdominal striae.

Arrange the following diagnostic steps in the most appropriate sequential order to establish the diagnosis and definitively localize the source of this patient's condition, assuming each successive biochemical test points toward a pituitary origin but initial anatomic imaging remains equivocal.

Match each clinical presentation of a symptomatic neonate with the most appropriate first-line management for the underlying congenital infection.

A $35$-year-old woman is brought to the emergency department by her husband due to progressive confusion and lethargy that began yesterday. Over the past week, she has complained of profound fatigue, intermittent nausea, and a low-grade fever. She has no significant past medical history and takes no medications. On physical examination, her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, pulse is $105/\text{min}$, and respirations are $16/\text{min}$. She is mildly disoriented to time and place. Examination of her skin reveals diffuse petechiae and purpura over her bilateral lower extremities. Laboratory studies show:

Hemoglobin: $7.8\text{ g/dL}$
Platelet count: $22,000/\text{mm}^3$
Leukocyte count: $7,200/\text{mm}^3$
Blood urea nitrogen: $35\text{ mg/dL}$
Serum creatinine: $2.4\text{ mg/dL}$
Total bilirubin: $3.2\text{ mg/dL}$
Indirect bilirubin: $2.6\text{ mg/dL}$
Lactate dehydrogenase (LDH): $950\text{ U/L}$
Direct antiglobulin (Coombs) test: Negative
Prothrombin time (PT): $12\text{ seconds}$
Activated partial thromboplastin time (aPTT): $30\text{ seconds}$

A peripheral blood smear reveals numerous schistocytes.

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

A 19-year-old female collegiate rugby player arrives at the trauma center via ambulance shortly after sustaining an injury during a match. Witnesses report she was forcefully tackled and struck in the left abdomen by an opponent's knee. Upon arrival, her temperature is $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), heart rate is $138/\text{min}$, blood pressure is $76/42\text{ mmHg}$, and respiratory rate is $26/\text{min}$. Oxygen saturation is $95\%$ on room air. The patient is lethargic but localizes to painful stimuli. The airway is patent, and breath sounds are vesicular and equal bilaterally. The abdomen is grossly distended with severe diffuse tenderness to palpation, guarding, and rebound tenderness. A large ecchymosis is present over the left upper quadrant. The pelvis is stable to anterior-posterior and lateral compression. Bedside ultrasound of the abdomen demonstrates a significant anechoic collection in the splenorenal recess and the rectouterine pouch. Which of the following is the most appropriate next step in the management of this patient?

A $42$-year-old man presents to the clinic for follow-up of hypertension. His blood pressure remains poorly controlled at $165/100$ mmHg despite adherence to maximum doses of amlodipine, lisinopril, and chlorthalidone. Laboratory results reveal a serum potassium level of $3.1$ mEq/L. The physician suspects secondary hypertension due to primary hyperaldosteronism.

Arrange the following diagnostic steps in the correct sequential order to evaluate and localize this patient's suspected condition.

A 74-year-old man is brought to the emergency department by his daughter due to severe pain and swelling in his right knee that began 18 hours ago. He cannot bear weight on the affected leg. His medical history is significant for primary hyperparathyroidism, osteoarthritis, and stage 3 chronic kidney disease. His temperature is 38.0°C (100.4°F), blood pressure is 142/88 mmHg, and pulse is 96/min. Physical examination reveals a swollen, warm, and erythematous right knee with a palpable effusion. Range of motion is severely limited by pain. Arthrocentesis yields 25 mL of cloudy yellow synovial fluid. Laboratory analysis of the fluid reveals a leukocyte count of 32,000/mm³ with 82% neutrophils. Polarized light microscopy of the fluid demonstrates rhomboid-shaped, weakly positively birefringent crystals. Gram stain of the synovial fluid shows no organisms. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man presents to the primary care office for evaluation of profound sluggishness and persistent constipation over the last five months. He mentions that he needs to wear a heavy sweater even when indoors because he constantly feels chilled. His medical background is significant for surgical removal of a large benign pituitary mass three years prior. On physical examination, his heart rate is 58/min, and there is a noticeable delay in the relaxation phase of his Achilles reflexes. Laboratory testing reveals the following:

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

A 26-year-old man is evaluated in the emergency department after a mountain biking accident. He lost control on a steep downhill trail and was thrown over the handlebars, striking his left flank against a large tree stump. He complains of severe left-sided abdominal pain that radiates to his left shoulder.

His temperature is 37.1°C (98.8°F), blood pressure is 132/84 mmHg, heart rate is 86/min, and respiratory rate is 16/min. On physical examination, the patient is alert and oriented. There is an abrasion and extensive ecchymosis over the left lower rib cage. Abdominal examination reveals tenderness to palpation in the left upper quadrant, but no guarding, rigidity, or rebound tenderness is present. The pelvis is stable to anteroposterior and lateral compression.

A bedside focused assessment with sonography for trauma (FAST) demonstrates a small accumulation of anechoic fluid in the splenorenal recess.

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

Match each clinical presentation of an infectious disease to its most appropriate, targeted first-line pharmacotherapy.

Match each clinical presentation of a sexually transmitted infection to its most appropriate definitive antimicrobial management strategy based on current guidelines.

A patient in the surgical intensive care unit develops oliguria on the second day following an elective partial colectomy. Over the past 8 hours, the urinary catheter has drained only 150 mL of highly concentrated urine. The patient has been receiving maintenance intravenous fluids at a conservative rate due to a known history of heart failure with preserved ejection fraction.

Vital signs show a temperature of 37.2°C (99.0°F), heart rate of 105/min, and blood pressure of 102/65 mmHg. Physical examination reveals dry oral mucosa and flat jugular veins.

Laboratory studies are obtained:

Based on the provided laboratory values, calculate the patient's fractional excretion of sodium (FENa). (Enter your answer as a percentage.)

An obstetric patient at 39 weeks gestation is admitted to the labor suite for induction of labor due to chronic hypertension. A continuous oxytocin infusion is currently being administered to augment uterine contractions. The patient's blood pressure is 138/88 mmHg. The continuous electronic fetal monitor displays a baseline heart rate of 145/min with moderate variability. The tracing demonstrates recurrent, gradual decreases in the fetal heart rate, with each deceleration starting after the peak of a uterine contraction and returning to baseline only after the contraction has completely finished. The contractions are occurring every 2 to 3 minutes. Cervical examination shows 5 cm dilation and 90% effacement. Which of the following is the most appropriate initial step in the management of this patient?

A surgical team is called to assess a 68-year-old male inpatient 48 hours following an open repair of a large ventral hernia. The patient is reporting new-onset shortness of breath that began earlier in the shift. His medical history is significant for chronic obstructive pulmonary disease and heart failure with preserved ejection fraction. When asked to take a deep breath, he stops abruptly and states that the maneuver causes sharp pain localized specifically around his abdominal incision. His temperature is 37.9°C (100.2°F), pulse is 108/min, respirations are 24/min, and blood pressure is 138/86 mm Hg. Pulse oximetry shows an oxygen saturation of 91% on room air. Physical examination reveals a well-approximated surgical site that is tender to palpation, with no surrounding erythema or purulent drainage. Jugular venous pulsation is visible 2 cm above the sternal angle. Auscultation of the chest reveals decreased breath sounds at both lung bases. No wheezes, crackles, or cardiac murmurs are appreciated. The patient's calves are soft, non-tender, and without edema. Which of the following is the most appropriate initial step in the management of this patient?

A 17-month-old boy is brought to the urgent care clinic by his parents in January due to a newly developed cough. The parents report that he had a runny nose and a mild fever for the past two days, but last night his cough became harsh and sounded like a barking seal. His voice has also become progressively hoarse. His medical history is unremarkable, and his immunizations are up to date. His temperature is 38.1°C (100.6°F), heart rate is 128/min, respiratory rate is 28/min, and oxygen saturation is 98% on room air. On physical examination, the child is well-appearing, alert, and comfortable while sitting in his mother's lap. When the physician begins the examination, the child starts crying, and a high-pitched inspiratory sound becomes clearly audible. There is no drooling, nasal flaring, or intercostal retractions. Auscultation of the lungs reveals clear breath sounds bilaterally without any expiratory wheezing. Which of the following is the most appropriate next step in the management of this patient?