All practice questions

A 68-year-old man is evaluated on postoperative day 6 following a sigmoid colectomy for colon adenocarcinoma. He reports sudden-onset shortness of breath and right-sided pleuritic chest pain. His past medical history includes chronic obstructive pulmonary disease and hypertension. His medications include subcutaneous unfractionated heparin, which was started on postoperative day 1. Temperature is 37.8°C (100.0°F), blood pressure is 128/82 mm Hg, pulse is 114/min, and respiratory rate is 24/min. Pulse oximetry is 90% on room air. Physical examination reveals decreased breath sounds at the right lung base and a swollen, tender right calf. Laboratory studies show:

Hemoglobin: 11.5 g/dL
Leukocyte count: 9,800/mm³
Platelet count: 52,000/mm³ (baseline was 260,000/mm³ prior to surgery)
Creatinine: 1.2 mg/dL

Arterial blood gas on room air:
pH: 7.32
PaCO2: 28 mm Hg
PaO2: 60 mm Hg
HCO3-: 14 mEq/L

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

An $82$-year-old female resident of an assisted living facility is evaluated in the hospital following a mechanical fall. The patient reports that she tripped over an electrical cord in her room earlier today. She now experiences severe pain in her right groin and is completely unable to bear weight. Prior to this incident, she was ambulatory and walked independently with a cane. Her past medical history is notable for osteoporosis, type $2$ diabetes mellitus, and essential hypertension. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $135/85\text{ mm Hg}$, pulse is $88/\text{min}$, and respirations are $14/\text{min}$. On physical examination, the right lower extremity is noticeably shorter than the left and lies in an externally rotated position. Distal pulses are strong and symmetric, and sensory function is intact in both legs. Plain radiographs of the pelvis and right hip demonstrate a complete, displaced fracture line extending across the transcervical region of the right femur. The greater and lesser trochanters are intact. What is the most appropriate definitive surgical management for this patient's injury?

An 82-year-old female resident of a skilled nursing facility is transported to the acute care clinic complaining of severe, crampy abdominal pain accompanied by intractable vomiting for the past 4 days. Her caregivers report that over the last 24 hours, her emesis has become dark brown with a distinct foul, fecal odor. She has not passed flatus or had a bowel movement for 48 hours. Medical history is significant for type 2 diabetes mellitus, coronary artery disease, and heart failure with preserved ejection fraction.

Vital signs include:
- Temperature: $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$)
- Heart rate: $118/\text{min}$
- Blood pressure: $92/58\text{ mmHg}$
- Respiratory rate: $22/\text{min}$

Physical examination reveals a markedly distended, tympanic abdomen with high-pitched, tinkling bowel sounds. There is diffuse abdominal tenderness to palpation but no guarding or rigidity.

Laboratory studies demonstrate a leukocyte count of $15,200/\text{mm}^3$. A basic metabolic panel shows:
- $\text{Na}^+$: $134\text{ mEq/L}$
- $\text{K}^+$: $3.1\text{ mEq/L}$
- $\text{Cl}^-$: $92\text{ mEq/L}$
- $\text{HCO}_3^-$: $34\text{ mEq/L}$
- $\text{BUN}$: $48\text{ mg/dL}$
- $\text{Creatinine}$: $1.8\text{ mg/dL}$

Arterial blood gas on room air shows $\text{pH} = 7.50$ and $\text{pCO}_2 = 45\text{ mmHg}$.

An upright plain radiograph of the abdomen reveals dilated loops of small intestine with multiple air-fluid levels. Additionally, there are branching radiolucent lines seen over the right upper quadrant (overlying the liver shadow) and a distinct $3.5\text{-cm}$ radiopaque density projected in the right lower quadrant.

After initiating aggressive intravenous fluid resuscitation and placing a nasogastric tube, which of the following is the most appropriate next step in the management of this patient?

A 72-year-old woman presents to the emergency department with a 3-week history of severe aching and morning stiffness in her shoulders and hips that lasts for several hours. Over the past 3 days, she has developed a throbbing, new-onset right-sided headache and reports that her jaw aches and tires easily when she chews solid foods. Her temperature is 37.9°C (100.2°F), blood pressure is 138/85 mmHg, and heart rate is 88/min. Physical examination reveals scalp tenderness on the right side and prominent, rope-like temporal arteries. Neurologic examination is unremarkable, and visual acuity is currently intact. Laboratory studies show an erythrocyte sedimentation rate of 98 mm/h and a C-reactive protein of 45 mg/L. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old patient is undergoing evaluation for secondary causes of hypertension and electrolyte abnormalities. The physician orders a plasma aldosterone concentration and plasma renin activity panel. Match the following laboratory profiles to their most likely underlying etiology.

A 62-year-old man with a 15-year history of poorly controlled type 2 diabetes mellitus and peripheral neuropathy is evaluated in the clinic for a chronic right foot ulcer. He first noticed the ulcer 6 weeks ago. The patient is afebrile, and his vital signs are strictly within normal limits. On physical examination, there is a $3 \times 3$ cm non-tender ulcer on the plantar surface of the right first metatarsal head. There is no surrounding erythema, warmth, fluctuance, or purulent drainage. A sterile metal probe is introduced into the ulcer and easily palpates a hard, gritty surface at the base. The physician highly suspects underlying osteomyelitis.

Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the standard medical management of this patient.

Match each brief clinical presentation to the most appropriate initial or highly specific diagnostic serologic marker.

A 34-year-old woman is brought to the emergency department for severe, progressive mid-abdominal pain and bilious emesis over the past 24 hours. She has not passed flatus or stool since the pain began. Her medical history includes Crohn disease, which necessitated a terminal ileal resection 7 years ago due to fibrotic strictures. She also has a history of mild asthma and a peripartum cardiomyopathy 3 years ago that has since completely resolved. Current medications include adalimumab. Her temperature is 38.9°C (102.0°F), blood pressure is 88/54 mm Hg, and pulse is 126/min. On physical examination, the abdomen is markedly distended and tympanic. There is severe, diffuse abdominal tenderness with involuntary guarding and rebound tenderness. Bowel sounds are absent.

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

A 24-year-old woman is brought to the emergency department due to severe nausea, diffuse abdominal pain, and confusion. She has a history of type 1 diabetes mellitus but ran out of her insulin prescription three days ago. For the past 48 hours, she has had intractable vomiting, rendering her unable to tolerate oral intake. Her temperature is 37.1°C (98.8°F), blood pressure is 98/60 mm Hg, pulse is 118/min, and respirations are 24/min and deep. Physical examination reveals dry mucous membranes, decreased skin turgor, and diffuse abdominal tenderness without rebound or guarding.

Laboratory studies reveal:

Arterial blood gas (room air):

Which of the following best describes this patient's current acid-base disturbance?

A physician assesses a 77-year-old female patient on the third day following surgical repair of a right femoral neck fracture. The patient reports a sudden onset of severe difficulty breathing and the inability to lie flat in bed, which began approximately one hour ago. Her past medical history includes essential hypertension, diet-controlled type 2 diabetes, and severe tobacco use disorder with associated chronic obstructive pulmonary disease. Since her operation, she has received continuous isotonic saline infusions due to transient intraoperative hypotension. Current vital signs demonstrate a temperature of 38.1°C (100.6°F), blood pressure of 168/92 mmHg, pulse of 115/min, and respirations of 28/min. Pulse oximetry shows an oxygen saturation of 86% on room air. Physical examination reveals prominent jugular venous distention. Lung auscultation demonstrates bilateral dependent fine inspiratory crackles without any expiratory wheezing. Cardiac evaluation reveals a regular tachycardia with a distinct early diastolic extra heart sound. The surgical incision is clean, dry, and intact. Which of the following is the most appropriate initial medical intervention for this patient?

Following an industrial accident where he was struck in the torso by a swinging steel pipe, a 48-year-old construction worker is transported to the trauma bay. Upon arrival, his blood pressure is 82/48 mm Hg, heart rate is 126/min, and respiratory rate is 22/min. Oxygen saturation is 97% on room air. The patient is lethargic but appropriately protects his airway. The trachea is midline, and breath sounds are clear and equal bilaterally. Heart sounds are normal. The abdomen is distended and exhibits diffuse tenderness to palpation, with involuntary guarding. Anteroposterior and lateral compression of the pelvis does not elicit pain or instability. Peripheral pulses are weak and thready. Two large-bore intravenous lines are established, and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A 58-year-old man is brought to the emergency department by his wife due to fever, severe headache, and confusion that started 12 hours ago. His wife reports that he has also been dragging his right leg since the onset of symptoms. His temperature is 39.2°C (102.6°F), blood pressure is 145/90 mm Hg, and pulse is 110/min. Physical examination reveals marked nuchal rigidity and right-sided hemiparesis. He is lethargic but arouses to verbal stimuli. Arrange the following management steps in the most appropriate chronological order.

Match each of the following eponymous forearm and wrist fractures with its correct anatomical injury description.

Paramedics transport a 55-year-old male pedestrian to the trauma center after he was struck by a moving delivery van. He complains of excruciating pain in his lower abdomen and hips. On primary assessment, his airway is patent, and breath sounds are equal bilaterally. His blood pressure is 78/42 mm Hg, and his pulse is 135/min. Physical examination demonstrates marked bruising over the suprapubic region. Gentle lateral compression of the iliac crests reveals a mechanically unstable pelvic ring. A pelvic binder is immediately applied, and 1 liter of intravenous Lactated Ringer's solution is infused rapidly. A bedside ultrasound (FAST) examination reveals an anechoic stripe in the hepatorenal recess. Repeat vital signs show a blood pressure of 82/46 mm Hg and a pulse of 128/min. Which of the following is the most appropriate next step in management?

Paramedics bring a 64-year-old woman to the emergency department due to acute respiratory distress that began 2 hours ago. She reports severe difficulty breathing and the sensation of smothering, which worsens significantly when she tries to lie flat on the stretcher. Her medical history includes long-standing hypertension, diet-controlled type 2 diabetes mellitus, and a 30-pack-year history of cigarette smoking. Upon arrival, her blood pressure is 182/104 mmHg, heart rate is 112/min, and respiratory rate is 26/min. Pulse oximetry shows an oxygen saturation of 88% on room air. Physical examination reveals an anxious patient sitting upright and utilizing accessory muscles of respiration. Jugular venous pressure is visibly elevated. Pulmonary auscultation reveals bilateral basilar crackles and prominent diffuse expiratory wheezing. Cardiac auscultation is notable for a regular tachycardia and an audible S3 gallop. In addition to providing supplemental oxygen, which of the following is the most appropriate initial pharmacological intervention for this patient?

Match each patient's clinical presentation and multiphasic abdominal imaging findings with the most likely primary hepatic lesion.

A 29-year-old woman is evaluated in the clinic as a new patient. She has no complaints and reports feeling well. She exercises regularly, follows a balanced diet, and takes no medications or supplements. Her father has a history of asymptomatic hypercalcemia that has never required medical treatment. Vital signs are within normal limits. Physical examination is unremarkable.

Laboratory studies show:

A 24-hour urine collection yields:

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

A 42-year-old woman is evaluated in the surgical telemetry unit on postoperative day 6 following a laparoscopic Roux-en-Y gastric bypass. Over the past 4 hours, she has reported rapidly worsening left shoulder pain and severe diffuse abdominal pain. She has no history of trauma to her shoulder. Her temperature is 39.1°C (102.4°F), blood pressure is 82/50 mm Hg, pulse is 134/min, and respirations are 26/min. Pulse oximetry is 94% on room air. She is diaphoretic, mottled, and appears in significant distress. Abdominal examination reveals a rigid, board-like abdomen with diffuse guarding and severe rebound tenderness. The laparoscopic port sites are clean, dry, and intact. A peripheral intravenous line is established, and rapid infusion of isotonic crystalloid is initiated, but her blood pressure remains 84/52 mm Hg. Which of the following is the most appropriate next step in management?

A 55-year-old man presents to the emergency department reporting the sudden onset of agonizing epigastric pain that rapidly generalized to his entire abdomen. The pain began approximately 2 hours ago. His past medical history is significant for osteoarthritis, for which he takes diclofenac regularly. On arrival, his temperature is 38.3°C (100.9°F), blood pressure is 108/68 mm Hg, and pulse is 112/min. Physical examination demonstrates a patient lying completely still on the stretcher. His abdomen is markedly rigid and board-like, with diffuse involuntary guarding and rebound tenderness. Arrange the following management steps in the most appropriate chronological order for this patient.

While recovering on the surgical ward six days after an emergency laparotomy for a perforated duodenal ulcer, a patient experiences a sudden 'popping' sensation in his abdomen during an intense coughing spell. The evaluating nurse notes that the surgical staples have separated, and segments of the small intestine are visibly protruding through the fascial defect onto the skin surface. The patient is tachycardic but maintaining his airway. Arrange the following medical interventions in the correct chronological order to appropriately manage this acute complication.