All practice questions

A 24-year-old woman presents to the outpatient clinic with a 3-month history of severe fatigue, symmetric pain in her bilateral wrists and metacarpophalangeal joints, and a photosensitive erythematous rash over her cheeks and nasal bridge. She is suspected of having a new-onset systemic autoimmune connective tissue disease. Arrange the following diagnostic and therapeutic steps in the appropriate clinical and chronological sequence for her suspected condition, starting from initial screening to the management of potential severe complications.

Match each esophageal motility disorder with its characteristic high-resolution manometry (HRM) findings according to the Chicago Classification.

A 22-year-old woman presents to the clinic for evaluation of easy bruising and prolonged bleeding following minor cuts. She reports a history of heavy menses since menarche, which occasionally requires iron supplementation. Her mother experiences similar mucosal bleeding symptoms. Physical examination reveals several small ecchymoses on her lower extremities but no petechiae. Vital signs are within normal limits. Arrange the following clinical steps in the most appropriate chronological sequence for the diagnostic workup and management of this patient's most likely condition.

An 81-year-old male resident of a skilled nursing facility is transported to the acute care unit following an episode of massive rectal bleeding. The nursing staff reports he passed several large clots of dark red blood and subsequently experienced presyncope. Upon arrival, he is pale, diaphoretic, and lethargic. Vital signs demonstrate a temperature of 36.1°C (97.0°F), a blood pressure of 78/42 mm Hg, and a pulse of 134/min. His medical history includes ischemic cardiomyopathy, chronic kidney disease, and advanced osteoarthritis, for which he takes daily naproxen and apixaban. Abdominal examination reveals normal bowel sounds and no guarding, rigidity, or focal tenderness. The rectal vault contains abundant fresh blood without palpable masses. Arrange the following interventions in the most appropriate sequential order for the management of this patient's acute presentation.

Emergency medical personnel deliver a 19-year-old male to the emergency department following a gunshot wound to the abdomen. The patient is confused and visibly pale. Initial vital signs include a blood pressure of 72/42 mm Hg, a heart rate of 145/min, and respirations of 26/min. Examination shows a single bullet entry hole in the periumbilical region with no corresponding exit wound. The abdominal wall is rigid, and generalized guarding is present. Bilateral breath sounds are clear. Large-bore intravenous access is obtained, and a massive transfusion protocol is initiated. Which of the following is the most appropriate next step in the management of this patient?

Match each classic peripheral manifestation of infective endocarditis with its correct clinical description.

An intensive care physician evaluates a 72-year-old male on his fourth day of hospitalization for severe community-acquired pneumonia complicated by septic shock. The patient is currently mechanically ventilated and receiving vasopressor support. His condition is slowly stabilizing, and the vasopressor requirements have decreased over the past $24\ \text{hours}$. His past medical history is notable for type 2 diabetes mellitus, hypertension, and benign prostatic hyperplasia. Current medications include continuous infusions of norepinephrine and propofol, subcutaneous insulin, and prophylactic enoxaparin. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $110/70\ \text{mmHg}$, and heart rate is $88/\text{min}$. A comprehensive metabolic panel and thyroid function tests are obtained as part of a routine morning evaluation. The thyroid panel reveals the following:

Serum thyroid-stimulating hormone (TSH): $1.1\ \mu\text{U/mL}$ (Normal: $0.4\text{--}4.2\ \mu\text{U/mL}$)
Free thyroxine ($\text{T}_4$): $1.2\ \text{ng/dL}$ (Normal: $0.8\text{--}2.7\ \text{ng/dL}$)
Total triiodothyronine ($\text{T}_3$): $45\ \text{ng/dL}$ (Normal: $80\text{--}200\ \text{ng/dL}$)

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

A 58-year-old man presents to the emergency department complaining of sudden-onset, severe, crushing substernal chest pain that began 45 minutes ago and radiates to his left jaw. His blood pressure is 140/90 mmHg, heart rate is 92/min, respiratory rate is 16/min, and oxygen saturation is 98% on room air. Physical examination reveals an anxious, diaphoretic patient with normal heart sounds and clear lungs. Arrange the following initial management steps in the most appropriate chronological sequence for this patient.

A 42-year-old woman is brought to the emergency department via ambulance after being rescued from a house fire. Paramedics report the injury occurred exactly 2 hours prior to her arrival. On physical examination, she is in significant pain but has a patent airway with no signs of inhalation injury. She has deep partial-thickness and full-thickness burns involving her entire anterior torso, her entire left arm, and the anterior surface of her left leg. The remainder of her skin is uninjured. Her weight is $75\text{ kg}$. Large-bore intravenous access is established. Based on the most current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should be the initial rate of intravenous lactated Ringer solution administration for this patient in $\text{mL/hr}$?

Evaluate the provided arterial blood gas (ABG) and basic metabolic panel (BMP) profiles. Which clinical etiology most accurately corresponds to each laboratory pattern?

Match each clinical presentation of a patient recovering from abdominal surgery with the most likely postoperative complication.

An internal medicine consultation is requested for a 62-year-old male on his second day of recovery following an open partial colectomy for diverticulitis. The patient has a 40-pack-year smoking history and mild chronic obstructive pulmonary disease. He currently reports sharp abdominal pain, especially when taking a deep breath. His temperature is $38.6^{\circ}\text{C}$ ($101.5^{\circ}\text{F}$), blood pressure is $138/82\text{ mmHg}$, pulse is $102/\text{min}$, and respirations are $22/\text{min}$. Pulse oximetry shows $91\%$ on room air. Physical examination reveals decreased breath sounds at the lung bases bilaterally, with no wheezing or crackles. The abdomen is tender near the incision but without rebound or guarding. The surgical incision is clean, dry, and intact. Which of the following are the most appropriate initial steps in the management of this patient's current condition? (Select 2 options)

A 74-year-old woman is evaluated in the outpatient clinic for medical clearance 3 days prior to an elective right total hip arthroplasty. Her medical history includes well-controlled type 2 diabetes mellitus, essential hypertension, and osteoarthritis. She reports feeling well and explicitly denies fever, chills, flank pain, dysuria, or increased urinary frequency. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 128/78 mmHg, and a pulse of 76/min. Physical examination is unremarkable with no costovertebral angle tenderness or suprapubic pain. As part of a preoperative protocol mandated by the surgical center, a urinalysis and urine culture are obtained. The urinalysis reveals a specific gravity of 1.018, pH of 6.5, positive leukocyte esterase, positive nitrites, and 45 white blood cells per high-power field. Two days later, the urine culture grows $>10^5$ CFU/mL of *Klebsiella pneumoniae*. Antimicrobial susceptibility testing indicates the isolate is susceptible to cephalexin, ciprofloxacin, and trimethoprim-sulfamethoxazole. Which of the following is the most appropriate management regarding the patient's urinary findings?

A 32-year-old man comes to the clinic for follow-up of a diarrheal illness. Three days ago, he developed fever, diffuse abdominal cramping, and multiple episodes of watery, non-bloody diarrhea after attending a family picnic. He was seen at an urgent care clinic yesterday where a stool culture was obtained and intravenous fluids were administered. Today, he reports that his fever has resolved and his diarrhea is beginning to improve, though he still has 2 to 3 loose stools per day. He is able to tolerate oral fluids and feels well-hydrated. His temperature is 37.1°C (98.8°F), blood pressure is 122/80 mmHg, and pulse is 76/min. The urgent care clinic forwards his stool culture results, which are positive for non-typhoidal *Salmonella enterica*. Susceptibility testing shows the isolate is pan-susceptible. Which of the following is the most appropriate antimicrobial management?

A 42-year-old man is hospitalized for community-acquired pneumonia. He has a 15-year history of ankylosing spondylitis. On admission two days ago, a sputum Gram stain and culture grew *Streptococcus pneumoniae* that is pan-sensitive to all standard antimicrobial agents, and he was appropriately started on targeted intravenous ceftriaxone. Over the past 48 hours, he has received 4 liters of intravenous crystalloid fluids. Today, he develops acute-onset severe shortness of breath and orthopnea. His temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $150/50$ mm Hg, pulse is 110/min, and respirations are 26/min. Pulse oximetry shows 86% on room air. Physical examination reveals an early blowing diastolic murmur best heard at the left lower sternal border. Pulmonary auscultation reveals bilateral crackles in the middle and lower lung fields. Laboratory studies show:

Thyroid-stimulating hormone (TSH): $2.5$ mU/L
Total T4: $4.1$ $\mu$ g/dL (Normal: $5.0$ - $12.0$ $\mu$ g/dL)

Arterial blood gas (room air):
pH: $7.48$
pCO $_2$: $30$ mm Hg
pO $_2$: $55$ mm Hg

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

Emergency medical services bring a 26-year-old male construction worker to the trauma center after he was crushed under a collapsed retaining wall. The patient's primary survey reveals a patent airway, clear breath sounds bilaterally, and stable hemodynamics with a blood pressure of 118/76 mm Hg and a heart rate of 92/min. Secondary survey is notable for severe pelvic instability, marked perineal ecchymosis, and fresh blood visible at the urethral meatus. Digital rectal examination demonstrates a high-riding prostate. Assuming sequential workup eventually reveals a complete posterior urethral transection accompanied by an intraperitoneal bladder rupture, arrange the following management steps in the correct chronological sequence.

A 50-year-old male seeks medical attention at the emergency department after two days of progressively worsening, crampy periumbilical pain, progressive abdominal distension, and an inability to pass flatus or stool. He reports multiple episodes of bilious emesis. His surgical history is notable for an exploratory laparotomy following blunt abdominal trauma a decade ago. Vital signs show a heart rate of 98/min, blood pressure of 135/85 mm Hg, and respiratory rate of 16/min. The patient is afebrile. Abdominal examination demonstrates marked distension, hyperactive high-pitched bowel sounds, and generalized tympany without rigidity or rebound tenderness. Arrange the following management steps in the most appropriate chronological sequence for this patient.

During morning rounds, the surgical team evaluates a 68-year-old male who is currently on his fourth postoperative day following an elective open ventral hernia repair with mesh placement. He has a known medical history of moderate chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a left ventricular ejection fraction of 45%. Overnight, the patient developed worsening shortness of breath and an increased production of thick, yellow sputum.

Current vital signs are as follows:

Physical examination demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. The jugular venous pressure is estimated at 6 cm $H_2O$. There is no peripheral edema. The abdominal incision is clean, dry, and fully intact without erythema, warmth, or induration. A sputum culture that was obtained two days ago due to a mild, non-productive cough has just finalized; it demonstrates moderate growth of *Haemophilus influenzae*. Susceptibility testing confirms the organism is sensitive to amoxicillin, azithromycin, and levofloxacin.

Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

A 42-year-old woman is evaluated for poorly controlled blood pressure despite adherence to a three-drug antihypertensive regimen consisting of amlodipine, lisinopril, and chlorthalidone. Her blood pressure is 162/98 mm Hg, and laboratory studies reveal a serum potassium level of 3.1 mEq/L. Primary hyperaldosteronism is suspected. She is an appropriate surgical candidate and wishes to pursue a definitive surgical cure if eligible. Assuming each test in the diagnostic pathway yields results consistent with a surgically correctable unilateral aldosterone-producing adenoma, arrange the following steps in the correct chronological order for her diagnostic workup and management.

A 56-year-old man undergoes an emergent partial colectomy with primary anastomosis for ischemic colitis. Over the first four days following the procedure, his recovery is unremarkable and he transitions to a clear liquid diet. On the morning of his fifth hospital day, he reports new-onset lower abdominal discomfort, tenesmus, and frequent, small-volume loose stools. His temperature is 38.9°C (102°F), blood pressure is 128/82 mmHg, heart rate is 108/min, and respiratory rate is 16/min. Physical examination demonstrates a clean, well-approximated midline surgical incision without fluctuance, drainage, or erythema. There is localized tenderness in the suprapubic region. Digital rectal examination reveals a boggy, highly tender fullness anteriorly. Laboratory studies show a leukocyte count of 18,500/mm³. Which of the following is the most appropriate next step in the management of this patient?