All practice questions

A 29-year-old man arrives at the trauma center via ambulance following an altercation where he sustained a stab wound to the periumbilical region. En route, he received $1$ L of intravenous crystalloid. Upon arrival, he appears pale and confused. Vital signs show a temperature of $36.6^\circ\text{C}$ ($97.9^\circ\text{F}$), blood pressure of $78/45\text{ mm Hg}$, heart rate of $138\text{/min}$, and respiratory rate of $28\text{/min}$. The airway is clear, and bilateral breath sounds are normal. Examination of the abdomen reveals a $4$-cm transverse laceration $2\text{ cm}$ to the left of the umbilicus. The abdomen is rigid with severe diffuse tenderness and rebound. Intravenous access is secured with two large-bore peripheral catheters, and uncrossmatched blood transfusions are initiated. Which of the following is the most appropriate next step in management?

A surgical consult is requested for a 67-year-old woman who has been hospitalized for the past 3 days due to an acute exacerbation of chronic obstructive pulmonary disease. Since yesterday evening, she has been experiencing worsening, diffuse abdominal cramps and has had three episodes of bilious vomiting. Her last bowel movement was 48 hours ago, and she reports an inability to pass flatus. Her past medical history is significant for an open appendectomy in her twenties and a total abdominal hysterectomy a decade ago. Vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 90/56 mmHg, and a heart rate of 122 beats/minute. On physical examination, her abdomen is distended, tympanitic, and diffusely tender. There is marked guarding and rebound tenderness in all four quadrants. Laboratory studies reveal a leukocyte count of 18,500/mm³ with a 15% bandemia, and a serum lactate level of 4.2 mmol/L. An upright abdominal radiograph displays multiple dilated loops of small intestine with prominent air-fluid levels, and no air is seen in the colon or rectum. Which of the following is the most appropriate next step in the management of this patient?

A 38-year-old woman is referred to the endocrinology clinic due to progressive weight gain, facial plethora, and easy bruising over the past eight months. Physical examination reveals prominent supraclavicular fat pads, violaceous abdominal striae, and proximal muscle weakness. Her blood pressure is $155/95$ mm Hg. Suspecting Cushing syndrome, the physician decides to initiate a comprehensive diagnostic evaluation. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for this patient.

An emergency medical crew transports a 35-year-old female equestrian to the trauma bay after she was violently thrown from her horse and trampled. She arrives fully immobilized on a backboard with a cervical collar. Her airway is patent and self-maintained. Initial vital signs demonstrate a heart rate of 142/min, blood pressure of 72/38 mm Hg, and a respiratory rate of 26/min. Both lungs are clear to auscultation bilaterally, and heart sounds are crisp and normal. There is extensive ecchymosis across her anterior chest wall and lower abdomen. Pelvic compression elicits no crepitus or mechanical instability. A portable supine anteroposterior chest radiograph reveals a widened mediastinal silhouette and deviation of the trachea to the right, with no evidence of hemothorax or pneumothorax. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal space (Morison pouch) and the rectouterine pouch. Which of the following is the most appropriate next step in the management of this patient?

A primary care physician evaluates a 45-year-old woman who noticed an expanding area of redness on her right shin that began 48 hours ago. The affected region is tender to the touch, and she reports feeling mildly fatigued but denies chills, nausea, or recent trauma. Medical history is notable only for mild allergic rhinitis, for which she takes over-the-counter cetirizine. Her temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure is $122/78 \text{ mmHg}$, pulse is $84/\text{min}$, and respiratory rate is $14/\text{min}$. Physical examination reveals a $10 \times 6 \text{ cm}$ erythematous, warm, and swollen plaque on the anterior right lower leg. The margins are indistinct. There is no palpable fluctuance, purulent exudate, or ulceration. Tender right inguinal lymphadenopathy is present. Which of the following is the most appropriate initial pharmacotherapy for this patient?

Match each cardiovascular medication to its most characteristic adverse effect.

Match each patient's specific clinical presentation with the most likely corresponding gastrointestinal histologic finding observed on biopsy.

A $42$-year-old male construction worker comes to the primary care clinic for evaluation of profound fatigue, a $9$-kg ($20$-lb) weight gain, and diminished libido progressing over the last nine months. He has a history of chronic, severe lumbar radiculopathy following a workplace injury four years ago. His daily medications include extended-release oxycodone, duloxetine, and ibuprofen. Vital signs show a blood pressure of $118/76$ mmHg and a heart rate of $58$/min. Physical examination reveals a flat affect, dry skin, and a delayed relaxation phase of the Achilles tendon reflexes. Visual field testing is entirely normal. A comprehensive metabolic panel is unremarkable. Neuroimaging of the sella turcica with gadolinium reveals no masses or structural lesions.

Relevant laboratory results are as follows:

Which of the following is the most likely mechanism underlying this patient's endocrine laboratory abnormalities?

Match each clinical presentation of renal disease with the most likely corresponding glomerular pathology.

An emergency medical team is evaluating a 58-year-old male who developed excruciating, unremitting abdominal pain 6 hours ago. He reports no bowel movements or flatus for the past 48 hours. Ten years ago, he underwent an open appendectomy. His temperature is 38.6°C (101.5°F), blood pressure is 94/60 mmHg, pulse is 118/min, and respiratory rate is 22/min. On physical examination, the abdomen is markedly distended and tympanitic. Palpation elicits diffuse tenderness, which is most prominent in the periumbilical region, accompanied by involuntary guarding and rebound tenderness. Auscultation reveals absent bowel sounds. Laboratory analysis demonstrates a leukocyte count of 18,500/mm³ with 15% bands and a serum lactate level of 4.8 mmol/L. An upright abdominal radiograph displays multiple dilated loops of small intestine with air-fluid levels, and no free air under the diaphragm. Which of the following is the most appropriate next step in management?

A $32$-year-old female nurse presents to the clinic reporting a $6$-week history of persistent jitteriness, heat intolerance, and difficulty sleeping. She also reports a $4\text{-kg}$ ($8.8\text{-lb}$) weight loss during this period despite a normal appetite. The patient has no significant past medical history. She mentions feeling significant stress recently due to her upcoming wedding. Her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $138/78\text{ mm Hg}$, and pulse is $115/\text{min}$. On physical examination, she appears anxious and diaphoretic. A fine resting tremor is observed in her outstretched hands. The thyroid gland is nonpalpable and non-tender. There is no cervical lymphadenopathy, proptosis, or pretibial myxedema. Laboratory studies are obtained and reveal the following:

Which of the following is the most likely diagnosis?

A $45$-year-old man is brought to the burn center via helicopter after an industrial explosion. The incident occurred exactly $3$ hours prior to his arrival. He weighs $100$ kg. Physical examination reveals deep partial-thickness burns over his entire anterior trunk, entire right arm, and entire left arm. His airway is secure, and he is hemodynamically stable. Two large-bore intravenous lines are placed. Based on current Advanced Trauma Life Support (ATLS) guidelines (using $2 \text{ mL/kg} \times \%\text{TBSA}$ for adult thermal burns), at what rate (in $\text{mL/hr}$) should the intravenous lactated Ringer's solution be administered for the remainder of the first $8$-hour post-injury period?

A 65-year-old man is evaluated in the surgical unit for rapidly escalating abdominal pain on postoperative day 2 following an open umbilical hernia repair with mesh. His medical history includes obesity and poorly controlled type 2 diabetes mellitus. His temperature is 39.2°C (102.6°F), blood pressure is 86/50 mmHg, heart rate is 122/min, and respiratory rate is 24/min. He appears diaphoretic, anxious, and lethargic. Physical examination reveals an abdomen that is exquisitely tender out of proportion to the visible surface findings. The skin surrounding the surgical incision is erythematous, markedly edematous, and indurated. Palpation of the periwound area elicits a faint crackling sensation in the subcutaneous tissue. Removal of the surgical dressing reveals a small amount of cloudy, grayish exudate seeping from the wound edges. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old man with sickle cell disease comes to the urgent care center due to a 3-day history of productive cough, fever, and severe, sharp chest pain. He also reports increasing difficulty breathing over the last 24 hours. The patient takes folic acid and hydroxyurea daily. His temperature is 38.8°C (101.8°F), blood pressure is 114/72 mm Hg, pulse is 122/min, and respirations are 28/min. Pulse oximetry shows an oxygen saturation of 89% on room air. Physical examination reveals scleral icterus. Lung auscultation demonstrates decreased breath sounds and crackles in the right lower lung field.

Laboratory test results are as follows:

Arterial blood gas analysis on room air reveals:

A chest radiograph displays a new opacity in the right lower lobe. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's post-operative clinical presentation following gastric or bariatric surgery with the most likely diagnosis.

An 81-year-old male resident of a skilled nursing facility is assessed on postoperative day $2$ after undergoing an open cholecystectomy for acute gangrenous cholecystitis. The patient has become increasingly short of breath over the last $4$ hours. His medical history is significant for chronic obstructive pulmonary disease, hypertension, and ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$. The operative report notes that he received $4.5$ liters of crystalloid resuscitation due to transient intraoperative hypotension. His temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure is $152/90$ mmHg, pulse is $114/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows $88\%$ on room air. Physical examination reveals jugular venous distention to $11 \text{ cm } H_2O$. Cardiac auscultation reveals a regular tachycardia and a prominent S3 gallop. Pulmonary examination demonstrates bibasilar crackles extending to the mid-lung fields without wheezing. The surgical incision is clean, dry, and intact. Which of the following is the most appropriate next step in management?

A 68-year-old man is evaluated in the emergency department for a 3-day history of high fever, productive cough, and progressive shortness of breath. His medical history includes type 2 diabetes mellitus and hypertension. He does not smoke. His temperature is 38.9°C (102°F), blood pressure is 90/55 mm Hg, pulse is 122/min, and respirations are 28/min. Pulse oximetry shows 88% on room air. Physical examination reveals a patient in severe respiratory distress with diminished breath sounds and coarse crackles over the right lower lung field.

Laboratory results:
Sodium: 140 mEq/L
Potassium: 4.6 mEq/L
Chloride: 102 mEq/L
Bicarbonate: 14 mEq/L
Blood urea nitrogen: 38 mg/dL
Serum creatinine: 1.6 mg/dL
Lactate: 6.1 mmol/L

Arterial blood gas on room air:
pH: 7.18
PaCO2: 38 mm Hg
PaO2: 58 mm Hg

Which of the following accurately describes this patient's acid-base disorders?

A $42$-year-old man is evaluated in the emergency department for a $3$-week history of progressively worsening right upper quadrant abdominal pain, high fevers, and a dry cough. He immigrated from a rural region of Central America $12$ years ago and returned there to visit relatives for a month, arriving back in the United States two months ago. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $110/70$ mm Hg, pulse is $112$/min, and respirations are $24$/min. Physical examination reveals scleral icterus and significant point tenderness over the right lower rib cage. Dullness to percussion is noted at the right lung base.

Arterial blood gas analysis on room air shows:

Additional laboratory studies show:

An abdominal ultrasound demonstrates a solitary, $8$-cm, hypoechoic lesion in the right hepatic lobe. To rule out a pyogenic source, an ultrasound-guided aspiration is performed, yielding a thick, odorless, dark-brown fluid. Gram stain shows abundant leukocytes but no organisms.

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

A $42$-year-old man presents with episodic severe headaches, diaphoresis, and palpitations. His blood pressure is $185/110$ mmHg and heart rate is $112$/min during an episode. A $24$-hour urine fractionated metanephrines test is markedly elevated. A non-contrast CT scan of the abdomen reveals a $4.5$-cm right adrenal mass. He is diagnosed with a pheochromocytoma and is scheduled for surgical resection in $3$ weeks. Arrange the following steps in the correct chronological sequence for the optimal preoperative and operative management of this patient.

A 26-year-old man weighing 90 kg is brought to the emergency department 2 hours after being rescued from a house fire. On primary survey, his airway is patent, and he is breathing spontaneously on supplemental oxygen without evidence of inhalation injury. Vital signs include a blood pressure of 110/70 mm Hg, heart rate of 115/min, and respiratory rate of 18/min. Physical examination reveals deep partial-thickness burns with blistering over his entire anterior trunk, entire left arm, and the anterior surface of his left leg. The skin on his face is erythematous and highly sensitive to touch, but no blisters are present. Two large-bore intravenous catheters were placed at the scene, but no intravenous fluids have been administered yet.

Based on current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what is the appropriate targeted intravenous fluid administration rate (in mL/hour) for the remainder of the first 8-hour period following the burn?