All practice questions

A $61$-year-old woman with a known history of advanced HIV (recent CD4 count $85/\text{mm}^3$) arrives at the emergency department accompanied by her daughter. She has a $2$-day history of progressively severe generalized headache, subjective fevers, and profound lethargy. Upon arrival, her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $110/65\text{ mmHg}$, pulse is $112/\text{min}$, and respirations are $18/\text{min}$. On physical examination, she is difficult to arouse and oriented only to person. Neck flexion produces involuntary hip and knee flexion. Neurologic evaluation reveals that the right pupil is $4\text{ mm}$ and sluggishly reactive, while the left is $2\text{ mm}$ and briskly reactive. Arrange the following diagnostic and therapeutic steps in the optimal chronological sequence for this patient's initial management.

A 62-year-old man with a history of metastatic prostate cancer is brought to the emergency department due to three days of progressively worsening mid-back pain. Over the last 12 hours, he has developed bilateral lower extremity weakness and urinary retention. Vital signs are within normal limits. Neurologic examination reveals 3/5 motor strength in the lower extremities bilaterally, 3+ patellar reflexes, and decreased sensation to pinprick below the level of the umbilicus. Post-void residual volume is 600 mL.

Arrange the following steps in the most appropriate sequential order for the management of this patient's current condition.

Match each classic clinical presentation to the most likely surgical diagnosis.

A 24-year-old primigravida at 24 weeks gestation comes to the clinic reporting frequent, unprovoked nosebleeds and a new rash on her lower extremities over the past two days. She feels fetal movement and has no other complaints. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $118/76 \text{ mmHg}$, and heart rate is $82/\text{min}$. Physical examination reveals scattered, non-blanching, pinpoint macules over her shins and ankles. The uterus is consistent in size with a 24-week gestation, and fetal heart rate is $145/\text{min}$ with normal variability.

Laboratory results are as follows:

A peripheral blood smear demonstrates a few enlarged platelets with normal morphology and a lack of schistocytes. Which of the following is the most appropriate next step in management?

A 62-year-old man is evaluated in the surgical ward on postoperative day 5 following an open anterior resection for severe rectal prolapse. Postoperative pain was managed with a lumbar epidural catheter, which was removed yesterday. He had been ambulating with assistance and tolerating a soft diet. Over the past 12 hours, he has developed a fever, chills, and increasing lower back pain. His temperature is 38.9°C (102.0°F), pulse is 110/min, respirations are 18/min, and blood pressure is 118/72 mm Hg. Physical examination reveals exquisite tenderness to palpation over the lower lumbar spine. Neurologic examination demonstrates 3/5 motor strength in the bilateral lower extremities and diminished sensation to pinprick below the L2 dermatome. A bedside bladder ultrasound reveals 600 mL of urine, despite the patient reporting no urge to void. The abdominal incision is clean, dry, and intact with no erythema or fluctuance. Which of the following is the most appropriate next step in management?

Emergency medical responders transport a $62$-year-old woman to the emergency department due to progressive lethargy and a four-day history of a productive cough. Her past medical history is significant for severe chronic obstructive pulmonary disease. Upon arrival, her temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $88/54\text{ mm Hg}$, pulse is $122/\text{min}$, and respirations are $26/\text{min}$. Oxygen saturation is $85\%$ on room air. Physical examination reveals a somnolent patient with prominent accessory muscle use, diffuse expiratory wheezing, and bilateral rhonchi. Laboratory results are as follows:

Arterial blood gas analysis (on room air):

Which of the following best characterizes this patient's acid-base status?

Match each clinical patient presentation with the most likely corresponding urinalysis sediment finding.

Match the following clinical presentations of couples experiencing infertility with their most appropriate first-line targeted fertility treatment or management strategy.

An emergency medical team brings a $68$-year-old man to the acute care facility due to the sudden onset of severe respiratory distress that awoke him from sleep. Over the past month, he has noted progressive fatigue and a $4$-kg ($8.8$-lb) weight gain. He has a $45$-pack-year smoking history. He reports a mild, productive cough over the last week. A sputum culture collected at his primary care physician's office three days ago grew *Haemophilus influenzae* susceptible to amoxicillin.

Upon arrival, he is speaking in short phrases and appears anxious.
Temperature: $37.1^{\circ}\text{C}$ ($98.8^{\circ}\text{F}$)
Blood pressure: $172/96 \text{ mm Hg}$
Pulse: $115\text{ /min}$, regular
Respirations: $26\text{ /min}$
Oxygen saturation: $88\%$ on ambient air

Physical examination reveals prominent distention of the external jugular veins when the patient is sitting upright. Cardiac auscultation demonstrates a normal S $1$ and S $2$ with an extra low-frequency diastolic sound. Pulmonary examination shows diffuse expiratory wheezing and bilateral inspiratory crackles extending to the mid-thoracic fields. The lower extremities exhibit $2+$ symmetric pitting edema.

Laboratory analysis reveals:
Thyroid-stimulating hormone (TSH): $1.4 \text{ }\mu\text{U/mL}$ (Normal: $0.5$-$5.0$)
Free thyroxine (T4): $0.6 \text{ ng/dL}$ (Normal: $0.9$-$1.7$)

Arterial blood gas analysis on ambient air:
pH: $7.46$
$\text{PaCO}_2$: $32 \text{ mm Hg}$
$\text{PaO}_2$: $56 \text{ mm Hg}$
$\text{HCO}_3^-$: $22 \text{ mEq/L}$

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

During an outpatient evaluation, a 28-year-old female patient reports experiencing profound anxiety, palpitations, and a $5$-kg ($11$-lb) weight loss over the past two months. She states she recently began taking various unprescribed "fat-burner" dietary supplements purchased online to prepare for a fitness competition. She denies any neck pain, recent viral illnesses, or changes in her vision. Her temperature is $37.0^{\circ}$ C ($98.6^{\circ}$ F), blood pressure is $135/75$ mm Hg, and pulse is $114$/min. Physical examination reveals a fine resting tremor of the outstretched hands, warm and moist skin, and brisk deep tendon reflexes. Ophthalmic examination shows no proptosis, lid lag, or periorbital edema. The thyroid gland is not palpable, and there is no cervical lymphadenopathy. Laboratory studies reveal:

Thyroid-stimulating hormone (TSH): $< 0.02$ $\mu$ U/mL
Free thyroxine (T4): $3.2$ ng/dL

Which of the following additional findings is most likely present in this patient?

A 61-year-old male is currently hospitalized on the surgical ward undergoing treatment for a mechanical small bowel obstruction. He was admitted two days ago with colicky abdominal pain, significant abdominal distention, and obstipation. His past medical history is notable for an exploratory laparotomy for a ruptured appendix during childhood.

Initial management with strict nothing-by-mouth status, intravenous crystalloids, and nasogastric tube decompression resulted in moderate symptomatic relief and decreased abdominal distention. However, over the past three hours, the nursing staff urgently requests an evaluation due to a dramatic clinical change.

The patient now complains of excruciating, unrelenting, and constant abdominal pain. His temperature is 39.1°C (102.4°F), pulse is 128/min, blood pressure is 88/52 mmHg, and respirations are 24/min. Physical examination reveals a rigid, distended abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are entirely absent. A point-of-care venous blood gas shows a pH of 7.28 and a lactate level of 5.2 mmol/L.

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

A $32$-year-old woman comes to the clinic reporting facial pressure and nasal congestion that began $5$ days ago. She states her symptoms started with a mild scratchy throat and clear rhinorrhea but have since progressed. Over the past two days, she has noticed thick, yellow-green nasal discharge and worsening pressure over her cheeks, which is exacerbated when leaning forward. She reports a subjective mild fever at home two days ago but has been afebrile since. Her medical history is unremarkable, and she takes no daily medications. Her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and pulse is $78/\text{min}$. Physical examination reveals erythematous, edematous nasal mucosa with purulent drainage in the bilateral middle meatus. There is mild tenderness to palpation over the maxillary sinuses. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a neonate with respiratory distress to its most likely underlying diagnosis.

During a routine employment health screening, a $28$-year-old man is found to have an incidental serum calcium level of $11.2$ mg/dL. The patient is entirely asymptomatic, reporting no fatigue, nephrolithiasis, bone pain, or abdominal discomfort. His family history is notable for mild, asymptomatic hypercalcemia in both his father and paternal aunt, neither of whom has undergone neck surgery. His renal function is normal. Arrange the following diagnostic and management steps in the correct chronological sequence to properly evaluate and manage this patient's condition.

Match each clinical presentation of a patient requiring initiation of antihypertensive therapy to the single most appropriate pharmacological class based on compelling indications and secondary clinical benefits.

A 48-hour-old female newborn is evaluated during routine nursery rounds. She was born at 39 weeks of gestation via an uncomplicated spontaneous vaginal delivery to a 28-year-old primigravid woman. Maternal prenatal testing was negative for HIV, syphilis, and hepatitis B. Group B Streptococcus screening was negative. The infant has been breastfeeding well and has established normal bowel and bladder function. Her temperature is 37.1°C (98.8°F), pulse is 130/min, and respiratory rate is 42/min. On physical examination, she is alert and well-appearing. Skin examination reveals numerous 2- to 3-mm yellow-white pustules on a broad base of irregular erythema. The lesions are clustered primarily on her chest, abdomen, and back, but completely spare the palms and soles. The remainder of the physical examination, including neurologic reflexes and tone, is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A $58$-year-old man is evaluated in the clinic for severe fatigue, nausea, and a mild headache that has progressively worsened over the past two weeks. His medical history is significant for metastatic melanoma, for which he began treatment with intravenous nivolumab $12$ weeks ago. His blood pressure is $90/60$ mmHg seated and $82/50$ mmHg upon standing. His pulse is $92$/min seated and $110$/min standing. Physical examination reveals no skin hyperpigmentation, rashes, or mucosal lesions. Visual fields are normal to confrontation. Laboratory results are as follows:

Which of the following is the most likely additional laboratory finding in this patient?

A 24-year-old male with no significant past medical history is undergoing an elective open reduction and internal fixation of a right clavicle fracture. Induction of general anesthesia is achieved with propofol and succinylcholine, and anesthesia is maintained with sevoflurane. Thirty minutes into the procedure, the anesthesiologist notes a sudden and abrupt rise in the end-tidal carbon dioxide ($ETCO_2$) to $78\text{ mmHg}$. The patient develops generalized muscle rigidity, most notably in the masseter muscles. His core body temperature begins to rise rapidly and is currently $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$). His heart rate is $152\text{/min}$, and blood pressure is $155/95\text{ mmHg}$.

Arrange the following management steps in the most appropriate chronological priority order for this patient's acute perioperative complication.

A $68$-year-old man comes to the office due to a $4$-week history of progressive fatigue, tremors, and a $5$-kg ($11$-lb) weight loss. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$ and recurrent sustained ventricular tachycardia. His medications include amiodarone, metoprolol, lisinopril, and spironolactone. His pulse is $112$/min and irregular, and blood pressure is $134/82$ mm Hg. Physical examination reveals a fine bilateral hand tremor and hyperreflexia. The thyroid gland is normal in size and non-tender on palpation. There is no proptosis or pretibial myxedema.

Laboratory results are as follows:

Color flow Doppler ultrasonography of the thyroid shows a structurally normal gland with markedly decreased vascularity. A $24$-hour radioactive iodine uptake scan reveals $<1\%$ uptake.

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

An emergency medical response team transports a young adult male to the hospital after he was discovered lethargic in his dormitory. The patient, a 22-year-old college student with a known psychiatric history, reportedly ingested a large, unknown quantity of over-the-counter pain relievers earlier in the day. Upon arrival at the triage desk, he is tachypneic and diaphoretic. Vital signs include a temperature of 38.1°C (100.6°F), blood pressure of 112/68 mm Hg, heart rate of 115/min, and respiratory rate of 28/min.

Laboratory evaluation is obtained immediately:

Sodium: $140$ mEq/L
Potassium: $4.2$ mEq/L
Chloride: $103$ mEq/L
Bicarbonate: $13$ mEq/L
Blood urea nitrogen: $18$ mg/dL
Creatinine: $1.0$ mg/dL

Arterial blood gas parameters on room air:
pH: $7.43$
PaCO2: $20$ mm Hg
PaO2: $98$ mm Hg

Based on the provided laboratory parameters, which of the following accurately characterizes the primary acid-base disturbance(s) in this patient?