All practice questions

A 68-year-old man is evaluated on postoperative day 5 following an exploratory laparotomy and colon resection for ischemic colitis. He has a medical history of obesity and severe chronic obstructive pulmonary disease. While being assisted out of bed by the nursing staff, he has a violent coughing fit and reports a sudden "tearing" sensation in his abdomen. His temperature is 37.2°C (99.0°F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are 18/min. Physical examination reveals that the lower half of the surgical incision has separated, and several loops of small bowel are visibly protruding through the fascial defect onto the abdominal wall. Arrange the following management steps in the most appropriate chronological order.

A 34-year-old industrial worker is brought to the trauma bay after being involved in an accident with heavy machinery. On arrival, he has a pulsatile, massive hemorrhage from a mangled right leg. He is making gurgling sounds, his respiratory rate is 8/min, and he has a weak radial pulse of 130/min.

Arrange the following acute management steps in the correct chronological sequence according to current Advanced Trauma Life Support (ATLS) principles.

Evaluate the following clinical presentations and pair each patient with the most likely predominant morphologic abnormality expected on their peripheral blood smear.

A $59$-year-old male is admitted to the hospital due to progressive fatigue, abdominal distension, and reduced urine output over the past five days. He has a history of cirrhosis secondary to nonalcoholic steatohepatitis. One week ago, his outpatient diuretic regimen of spironolactone and furosemide was increased to manage worsening ascites. Vital signs on admission show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $98/58\text{ mm Hg}$, and pulse of $88/\text{min}$. Physical examination reveals shifting dullness and trace bilateral pedal edema, but no signs of asterixis or hepatic encephalopathy.

Laboratory studies on admission reveal:
- Serum sodium: $131\text{ mEq/L}$
- Serum creatinine: $2.6\text{ mg/dL}$ (baseline $1.0\text{ mg/dL}$ one month ago)
- Blood urea nitrogen: $54\text{ mg/dL}$
- Urinalysis: normal, with a fractional excretion of sodium (FENa) less than $1\%$
- Ascitic fluid analysis: $150\text{ neutrophils/mm}^3$

All diuretics are immediately discontinued, and he is treated with an intravenous infusion of albumin ($1\text{ g/kg/day}$) for $48$ hours. Re-evaluation today shows a serum creatinine of $2.7\text{ mg/dL}$. Renal ultrasound shows normal-sized kidneys with no hydronephrosis. Which of the following is the most appropriate next step in management?

A 45-year-old man develops severe hypoxemia and bilateral pulmonary infiltrates 48 hours after being admitted for severe acute pancreatitis. He is diagnosed with acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The pathogenesis of this condition follows a well-described sequence of inflammatory and structural changes in the lungs. Arrange the following pathophysiological events of acute respiratory distress syndrome in the correct chronological order from the initial insult to the late stages.

Match each dynamic auscultation or hemodynamic finding to the most likely underlying cardiovascular pathology.

A 55-year-old standardized patient is being utilized for a bedside physical examination OSCE. Examinees are required to evaluate jugular venous pulse (JVP) waveforms. Match each detailed description of a JVP waveform abnormality with the cardiovascular pathology that best explains its pathogenesis.

Match each structural heart pathology with its most characteristic physical examination findings.

Match each acute abdominal clinical presentation with its most appropriate initial definitive management strategy.

During morning rounds on his sixth postoperative day, a $60$-year-old male patient is noted to have a new-onset fever. Six days ago, he underwent an open sigmoid colectomy to treat complicated diverticulitis. His medical history is significant for obesity, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $132/84\text{ mm Hg}$, pulse is $102/\text{min}$, and respirations are $18/\text{min}$. Oxygen saturation is $94\%$ on room air. He reports generalized fatigue and worsening pain around his abdominal incision. Physical examination reveals mild bilateral basilar crackles that clear with coughing. The abdomen is non-distended. The midline laparotomy incision exhibits a $5\text{-cm}$ area of erythema, induration, and tenderness. Gentle pressure applied adjacent to the incision yields thick, purulent fluid from between two surgical staples. There is no calf tenderness or swelling. Which of the following is the most appropriate next step in management?

A $74$-year-old woman presents to the emergency department with severe, sudden-onset shortness of breath that began $2$ hours ago. She has a history of type 2 diabetes mellitus, essential hypertension, and a $40$-pack-year smoking history. Current medications include amlodipine, metformin, and atorvastatin. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $185/105\text{ mmHg}$, pulse is $112\text{/min}$, and respirations are $28\text{/min}$. Pulse oximetry shows $88\%$ on room air. The patient appears anxious, diaphoretic, and is sitting upright. Physical examination reveals prominent jugular venous distention. Lung auscultation demonstrates diffuse expiratory wheezing bilaterally with crackles at the lung bases. Cardiac auscultation reveals a regular tachycardia with a prominent third heart sound ($S_3$). Lower extremities show trace pitting edema. Which of the following is the most appropriate next step in management?

A 68-year-old male arrives at the emergency department reporting a two-day history of progressively worsening shortness of breath. He also notes a significant increase in his baseline daily cough and reports that his sputum has changed from clear to thick and yellow-green. He has a 45-pack-year smoking history and was diagnosed with chronic obstructive pulmonary disease (COPD) three years ago. Vital signs show a temperature of 37.5°C (99.5°F), blood pressure of 140/90 mmHg, heart rate of 108/min, and respiratory rate of 24/min. Pulse oximetry demonstrates an oxygen saturation of 89% on room air. Physical examination reveals a barrel-shaped chest, use of accessory muscles of respiration, and a prolonged expiratory phase with diffuse bilateral wheezing. Jugular venous pressure is normal, and there is no peripheral edema. An arterial blood gas analysis on room air reveals the following:

In addition to supplemental oxygen, which of the following is the most appropriate initial combination of pharmacotherapy for this patient?

Emergency medical services bring a 32-year-old male warehouse worker to the trauma center 30 minutes after he was pinned between a forklift and a concrete loading dock. He is awake, diaphoretic, and complains of agonizing pain in his hips and lower back.

Vital signs on arrival are temperature 36.8°C (98.2°F), blood pressure 76/40 mmHg, heart rate 138/min, and respiratory rate 24/min. The airway is patent, and breath sounds are equal bilaterally. The trachea is midline. Two large-bore intravenous catheters are placed, and 1 L of warmed lactated Ringer solution is administered rapidly. Following fluid resuscitation, his blood pressure remains 74/42 mmHg.

Physical examination reveals a rapidly expanding scrotal hematoma and a small amount of blood at the urethral meatus. Gentle anteroposterior compression of the iliac crests demonstrates gross mechanical instability, and a pelvic binder is immediately applied.

A bedside focused assessment with sonography for trauma (FAST) demonstrates no free fluid in the pericardial, pleural, or peritoneal cavities. A portable chest radiograph is normal. A portable anteroposterior pelvic radiograph confirms a 4-cm diastasis of the pubic symphysis and disruption of the left sacroiliac joint.

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

An otherwise healthy $48$-year-old female presents to the surgical assessment unit with a $24$-hour history of intermittent, crampy abdominal pain. She reports three episodes of bilious vomiting and states she has not passed flatus or stool since the pain began. Her surgical history is significant for a total abdominal hysterectomy performed five years ago for uterine fibroids.

Vital signs include a blood pressure of $122/78$ mmHg, heart rate of $82$/min, respiratory rate of $14$/min, and temperature of $37.0^\circ$ C ($98.6^\circ$ F). Physical examination reveals a moderately distended abdomen with high-pitched, 'tinkling' bowel sounds. The abdomen is softly to moderately tender diffusely, but there is no rigidity, guarding, or rebound tenderness.

Laboratory studies show a leukocyte count of $8,200$/mm $^3$ and a serum lactate level of $1.1$ mmol/L. A computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast demonstrates dilated loops of small bowel measuring up to $4.2$ cm with multiple air-fluid levels and a discrete transition point in the mid-ileum. The distal small bowel and colon are collapsed. There is no evidence of pneumatosis intestinalis, mesenteric fat stranding, or free intraperitoneal fluid.

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

An unresponsive 52-year-old male is transported to the triage area by paramedics after being found in a mechanic's garage. According to bystanders, he had been drinking an unidentified liquid from a jug. His temperature is 36.5°C (97.7°F), blood pressure is 150/92 mm Hg, pulse is 108/min, and respirations are 24/min and deep. He responds only to painful stimuli.

Laboratory studies show the following:
Sodium: $139$ mEq/L
Potassium: $4.8$ mEq/L
Chloride: $104$ mEq/L
Bicarbonate: $10$ mEq/L
Blood urea nitrogen (BUN): $14$ mg/dL
Creatinine: $1.8$ mg/dL
Glucose: $90$ mg/dL
Measured serum osmolality: $318$ mOsm/kg $H_2O$

Arterial blood gas (room air):
pH: $7.22$
$PCO_2$: $23$ mm Hg
$PO_2$: $98$ mm Hg

Based on the provided laboratory data, what is the patient's serum osmolar gap?

Brought to the emergency department by his wife, a 41-year-old man has exhibited worsening fatigue, severe headache, and episodic confusion over the past four days. His wife mentions that his behavior has been highly uncharacteristic. His past medical history includes major depressive disorder, for which he was recently prescribed fluoxetine. His temperature is 38.1°C (100.6°F), blood pressure is 145/88 mm Hg, and pulse is 102/min. Physical examination reveals scattered petechiae over his bilateral lower extremities and mild scleral icterus. Neurologic examination shows no focal deficits, but the patient is disoriented to time and place. Cardiopulmonary examination is unremarkable.

Laboratory studies show:
Hemoglobin: 7.8 g/dL
Platelet count: 18,000/µL
Leukocyte count: 8,400/µL
Creatinine: 2.1 mg/dL
Total bilirubin: 3.8 mg/dL
Indirect bilirubin: 3.2 mg/dL
Lactate dehydrogenase: 1,100 U/L

A peripheral blood smear demonstrates numerous fragmented red blood cells. Which of the following is the most appropriate next step in management for this patient?

Match each of the following Hepatitis B serologic profiles with the most accurate clinical interpretation. Assume all patients have normal liver enzymes and no clinical signs of acute liver failure.

A 45-year-old man presents to the emergency department with a 4-week history of productive cough, hemoptysis, drenching night sweats, and a $6\text{-kg}$ ($13\text{-lb}$) weight loss. He recently emigrated from a region highly endemic for tuberculosis. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $120/78\text{ mm Hg}$, and pulse is $92/\text{min}$. A chest radiograph reveals a $3\text{-cm}$ cavitary lesion in the right upper lobe. Arrange the following management steps in the most appropriate chronological sequence.

A 72-year-old man is brought to the emergency department due to the sudden onset of severe shortness of breath and a cough productive of pink, frothy sputum that began $1$ hour ago. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, mild chronic obstructive pulmonary disease (COPD), and poorly controlled hypertension. His current medications include lisinopril, metoprolol succinate, aspirin, and a tiotropium inhaler. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $220/120$ mmHg, pulse is $115$/min, and respirations are $32$/min. Pulse oximetry shows $84\%$ on room air. The patient is alert, oriented, and speaks in short, gasping phrases. Physical examination reveals use of accessory muscles of respiration. Auscultation of the lungs reveals diffuse, high-pitched expiratory wheezes bilaterally with no audible crackles. Cardiovascular examination reveals a regular tachycardia with a prominent $S_4$ gallop. There is no jugular venous distention or lower extremity edema. An arterial blood gas analysis on room air shows:

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

A 45-year-old man is evaluated for treatment-resistant hypertension. His current medications include amlodipine, olmesartan, and hydrochlorothiazide. His blood pressure is 165/100 mmHg. Laboratory studies reveal a serum potassium level of 3.1 mEq/L and a serum sodium level of 144 mEq/L. The physician suspects primary aldosteronism and appropriately transitions the patient's antihypertensive regimen to non-interfering medications (e.g., verapamil, doxazosin) for accurate biochemical testing. Arrange the following steps in the correct sequential order for the comprehensive diagnostic workup and pre-surgical evaluation of this patient, from initial screening to final functional lateralization.