All practice questions

Match each classic cardiovascular physical examination finding with the most likely underlying structural or valvular pathology.

A 54-year-old man collapses suddenly in the hospital cafeteria. He is unresponsive, apneic, and has no palpable pulse. A bystander has just brought an automated external defibrillator (AED) and the cardiac monitor pads are applied. The monitor displays coarse ventricular fibrillation. Arrange the following interventions in the most appropriate chronological sequence for the initial management of this patient according to standard advanced cardiac life support (ACLS) guidelines.

A $28$-year-old tall, thin man is brought to the emergency department after sudden-onset severe right-sided chest pain and extreme shortness of breath. Vital signs show a blood pressure of $82/50$ mm Hg, a heart rate of $135$/min, and an oxygen saturation of $84\%$ on room air. Examination reveals absent breath sounds over the right hemithorax, hyperresonance to percussion on the right, and distended jugular veins. Arrange the following management steps in the most appropriate chronological order.

Match each patient's clinical presentation and laboratory coagulation profile with the most likely underlying bleeding disorder.

A 51-year-old woman visits her primary care provider due to severe, unrelenting itchiness and worsening fatigue that has developed over the past eight months. She notes that her pruritus is particularly bothersome at night. The patient has no history of alcohol consumption, illicit drug use, or recent travel. Her body mass index is $24 \text{ kg/m}^2$. Vital signs are within normal limits. On physical examination, there is mild hepatomegaly, widespread skin excoriations, and hyperpigmentation. There is no ascites, splenomegaly, or palpable abdominal mass.

Laboratory testing shows:
- Total bilirubin: $2.5 \text{ mg/dL}$
- Direct bilirubin: $2.1 \text{ mg/dL}$
- Alkaline phosphatase: $610 \text{ U/L}$
- Aspartate aminotransferase (AST): $48 \text{ U/L}$
- Alanine aminotransferase (ALT): $52 \text{ U/L}$
- Antimitochondrial antibody (AMA): Positive (1:320)

An abdominal ultrasound demonstrates a normal-sized gallbladder and no intrahepatic or extrahepatic biliary ductal dilation.

Which of the following is the most appropriate initial medical therapy to slow the progression of this patient's underlying condition?

A 71-year-old woman is evaluated in the hospital during the night shift for acute-onset shortness of breath. She was admitted two days ago for acute pyelonephritis and has been receiving intravenous ceftriaxone alongside aggressive intravenous fluid resuscitation. Currently, she is visibly distressed and prefers to sit upright on the edge of the bed. Her temperature is 37.1°C (98.8°F), blood pressure is 158/92 mm Hg, pulse is 106/min, and respirations are 26/min. Pulse oximetry shows 88% on room air. Physical examination reveals prominent jugular venous distention. Lung auscultation demonstrates bilateral crackles extending to the mid-lung fields, with no wheezing. Cardiac examination reveals a regular rhythm, normal S1 and S2, and a distinct third heart sound (S3). There is 2+ bilateral lower extremity pitting edema. Which of the following is the most appropriate next step in management of this patient's current symptoms?

A $64$-year-old man presents to the urgent care clinic due to a $3$-day history of worsening shortness of breath. He reports that his baseline chronic cough has increased in frequency, and his sputum has changed from small amounts of clear mucus to copious amounts of thick, yellow-green phlegm. The patient has a history of severe chronic obstructive pulmonary disease (COPD) and uses daily inhaled tiotropium and as-needed albuterol. He smoked a pack of cigarettes daily for $40$ years but quit $2$ years ago. His temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure is $132/84\text{ mm Hg}$, pulse is $92/\text{min}$, and respiratory rate is $20/\text{min}$. Pulse oximetry is $94\%$ on room air. He is speaking in full sentences and is in no acute distress. Lung auscultation reveals a prolonged expiratory phase with diffuse bilateral wheezing, but no crackles are heard. Cardiovascular examination shows no jugular venous distension and no lower extremity edema. The physician administers nebulized albuterol and ipratropium and prescribes a $5$-day course of oral prednisone. Which of the following is the most appropriate additional step in management?

A 42-year-old woman is evaluated in the intensive care unit for persistent hypoxemia. She was admitted 3 days ago for severe acute pancreatitis and was intubated yesterday due to acute respiratory distress syndrome (ARDS). She is receiving a continuous intravenous infusion of fentanyl for analgesia and lactated Ringer solution. She has no other medical conditions.

The patient is sedated and paralyzed with a neuromuscular blocking agent.

Vital signs are temperature 37.9°C (100.2°F), pulse 118/min, and blood pressure 112/68 mm Hg.
Physical examination shows a jugular venous pressure of 6 cm H2O. Lung auscultation reveals bilateral diffuse crackles.

Hemodynamic monitoring shows a pulmonary capillary wedge pressure of 11 mm Hg and a cardiac index of 3.4 L/min/m2.

A chest radiograph demonstrates bilateral diffuse alveolar opacities.

Laboratory results are as follows:
Leukocyte count: 15,500/mm3
Thyroid-stimulating hormone (TSH): 1.1 µU/mL (Normal: 0.4–4.0 µU/mL)
Free T4: 0.6 ng/dL (Normal: 0.8–2.7 ng/dL)

A recent CT scan of the abdomen shows pancreatic necrosis without evidence of gas or infection. Blood cultures are sterile.

Arterial blood gas analysis on mechanical ventilation (Volume-assist control, Tidal volume 6 mL/kg ideal body weight, Respiratory rate 24/min, PEEP 8 cm H2O, FiO2 0.80):
pH: 7.30
pCO2: 52 mm Hg
pO2: 54 mm Hg
HCO3: 25 mEq/L

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

A 55-year-old man arrives at the emergency department reporting three days of worsening, diffuse abdominal cramps associated with intractable bilious emesis and an inability to pass stool or gas. His medical history is significant for a ruptured appendix requiring an open appendectomy 20 years ago. He was initially evaluated at an urgent care center yesterday and discharged with antiemetics. Over the past 6 hours, his pain has transitioned from intermittent cramping to severe, relentless, and unyielding discomfort. His temperature is 38.9°C (102.0°F), pulse is 126/min, respirations are 24/min, and blood pressure is 92/58 mm Hg. On physical examination, the patient lies completely still. His abdomen is significantly distended, diffusely rigid, and exhibits profound rebound tenderness. Bowel sounds, which he noted were "rumbling" yesterday, are now absent. Laboratory investigations demonstrate a leukocyte count of 19,500/mm³ and a serum lactate level of 4.8 mmol/L. A plain radiograph of the abdomen reveals multiple dilated loops of small intestine with prominent air-fluid levels and an absence of distal colonic gas. No pneumoperitoneum is identified. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old man is evaluated in the intensive care unit for ongoing management of ventilator-associated pneumonia. He was intubated 6 days ago for severe acute respiratory distress syndrome. Three days ago, he developed a new fever, increased purulent endotracheal secretions, and worsening oxygenation. At that time, empiric intravenous vancomycin, cefepime, and ciprofloxacin were initiated. Today, his temperature is 37.2°C (99.0°F), leukocyte count has decreased from 16,000/mm³ to 9,500/mm³, and his oxygen requirements have significantly improved. Blood cultures have shown no growth. Endotracheal aspirate culture from three days ago grows Pseudomonas aeruginosa. Susceptibility testing shows the isolate is susceptible to cefepime, piperacillin-tazobactam, and ciprofloxacin. A methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction screen performed on admission was negative, and no Gram-positive organisms are seen on the respiratory culture Gram stain. Which of the following is the most appropriate next step in antibiotic management?

A $72$-year-old man is evaluated in the intensive care unit for worsening abdominal pain, progressive distension, and high fever. He was admitted $8$ days ago for a complicated urinary tract infection and has been receiving intravenous ceftriaxone. Three days ago, he developed profuse, watery diarrhea, which abruptly ceased this morning. His temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $82/50\text{ mmHg}$, and pulse is $128\text{/min}$. Physical examination reveals a markedly distended, tympanic abdomen with diffuse tenderness and absent bowel sounds.

Laboratory studies show:

A stool nucleic acid amplification test is positive for *Clostridioides difficile*. A portable plain abdominal radiograph demonstrates a transverse colon diameter of $10.5\text{ cm}$, loss of haustral markings, and no evidence of free air.

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

Following a high-velocity collision during a collegiate rugby match, an athlete is transported to the trauma center complaining of progressive lightheadedness and severe left-sided abdominal pain. On arrival, the patient appears pale and diaphoretic. Vital signs show a heart rate of 128/min and a blood pressure of 82/50 mmHg. Primary survey reveals a patent airway, clear breath sounds bilaterally, and a rigid, distended abdomen with significant guarding. After rapid intravenous infusion of 1 liter of warmed lactated Ringer's solution, the blood pressure transiently improves to 105/65 mmHg but subsequently drops to 85/45 mmHg within 10 minutes. A bedside focused assessment with sonography for trauma (FAST) reveals a large amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in the management of this patient?

Match the following classic liver biopsy histological findings to the most appropriate chronic hepatobiliary disorder.

A 62-year-old man presents to the emergency department with sudden-onset, severe, tearing chest pain that radiates directly to his back between his scapulae. The pain started 30 minutes ago while he was watching television. His medical history is significant for poorly controlled essential hypertension and a 40-pack-year smoking history. His temperature is 37.0°C (98.6°F), blood pressure is 210/110 mm Hg in the right arm and 170/95 mm Hg in the left arm, heart rate is 112/min, and respiratory rate is 20/min. Physical examination reveals an early diastolic decrescendo murmur at the right upper sternal border. An electrocardiogram shows sinus tachycardia with no ischemic changes. A chest radiograph reveals a widened mediastinum. Based on the most likely diagnosis, arrange the following management steps in the most appropriate chronological sequence.

Match each clinical presentation of dysphagia and chest pain to its most characteristic high-resolution esophageal manometry finding.

Match each etiology of thyrotoxicosis to its characteristic laboratory and radioactive iodine uptake (RAIU) diagnostic profile.

A 68-year-old man with a history of type 2 diabetes mellitus is brought to the emergency department by his daughter due to progressive confusion and lethargy over the past three days. He recently had a mild upper respiratory infection. On physical examination, his temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $95/60\text{ mm Hg}$, and heart rate is $118/\text{min}$. The patient appears lethargic and has dry mucous membranes with delayed capillary refill.

Laboratory results are as follows:

Serum sodium: $132 \text{ mEq/L}$
Serum potassium: $3.1 \text{ mEq/L}$
Serum chloride: $98 \text{ mEq/L}$
Serum bicarbonate: $22 \text{ mEq/L}$
Blood urea nitrogen: $48 \text{ mg/dL}$
Serum creatinine: $1.9 \text{ mg/dL}$
Serum glucose: $940 \text{ mg/dL}$
Arterial blood gas (room air): pH $7.35$, pCO $_2$ $40 \text{ mm Hg}$, pO $_2$ $88 \text{ mm Hg}$

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

A 52-year-old man is brought to the emergency department by his wife due to a 24-hour history of severe generalized headache, high fever, and progressive confusion. His temperature is 39.4°C (102.9°F), blood pressure is 142/88 mmHg, and heart rate is 112/min. On physical examination, he is lethargic and oriented only to person. Neck flexion produces involuntary hip and knee flexion. Ophthalmoscopic examination reveals bilateral optic disc swelling with blurred margins. Arrange the following management steps in the most appropriate chronological order for this patient.

Emergency medical services bring a 58-year-old male to the emergency department due to the abrupt onset of excruciating, tearing chest pain radiating to his interscapular region. He has a history of poorly controlled hypertension. Vital signs show a blood pressure of $215/115$ mm Hg in his right arm and $180/95$ mm Hg in his left arm. His heart rate is $112$/min. Physical examination reveals a faint early diastolic decrescendo murmur at the right upper sternal border. An initial portable chest radiograph demonstrates a widened mediastinum.

Arrange the following management steps in the optimal chronological sequence to minimize the risk of catastrophic complications and ensure appropriate definitive care.

A 64-year-old man arrives at the emergency department via ambulance with sudden-onset, severe "tearing" chest pain that radiates to his back. His blood pressure is 215/115 mm Hg in the right arm and 175/95 mm Hg in the left arm. His heart rate is 118/min and regular. Physical examination reveals a new early diastolic decrescendo murmur at the right upper sternal border. An electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy. Chest radiography demonstrates a widened mediastinum. The clinical team suspects an acute type A aortic dissection. Arrange the following steps in the correct order for the most appropriate management of this patient.