All practice questions

Match each brief clinical presentation of chronic diarrhea to its most likely underlying etiology or pathogenesis.

A $65$-year-old man presents to the emergency department with a $2$-day history of colicky abdominal pain, intractable nausea, and failure to pass flatus or stool. He underwent an open appendectomy $20$ years ago. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse is $105/\text{min}$, and blood pressure is $118/76\text{ mmHg}$. Abdominal examination reveals a distended and tympanitic abdomen with high-pitched bowel sounds, but no rebound tenderness or guarding. Laboratory studies show a leukocyte count of $9,500/\text{mm}^3$ and normal serum lactate levels. An abdominal computed tomography (CT) scan reveals dilated small bowel loops with a transition point in the right lower quadrant, consistent with a mechanical small bowel obstruction, and no evidence of bowel ischemia.

Arrange the following steps in the most appropriate chronological sequence for the management of this patient, assuming his condition does not resolve with nonoperative measures.

A 42-year-old woman is transported to the emergency department after a grease fire erupted at the commercial kitchen where she works. The incident occurred exactly 3 hours before her arrival at the trauma center. She weighs $80 \text{ kg}$. On primary survey, her airway is patent, breathing is spontaneous but tachypneic, and hemodynamics are stable. Physical examination reveals deep partial-thickness and full-thickness burns involving her entire anterior trunk, her entire right arm, and the anterior surface of her right lower extremity. The remainder of her skin is uninjured. Using the traditional Parkland formula ($4 \text{ mL/kg/\%TBSA}$), at what rate (in $\text{mL/hour}$) should the initial intravenous crystalloid infusion be set to deliver the appropriate fluid volume over the remainder of the first 8-hour window?

A 74-year-old woman is admitted to the hospital with a 4-week history of progressively worsening exertional dyspnea, increased abdominal girth, and bilateral lower extremity swelling. She has a history of chronic obstructive pulmonary disease (COPD), essential hypertension, and obesity ($BMI$ 36 kg/m $^2$). Her current medications include amlodipine, lisinopril, and a tiotropium inhaler. Blood pressure is 155/92 mm Hg, pulse is 92/min, and respirations are 20/min. Pulse oximetry is 94% on room air. Jugular venous pressure is estimated at 12 cm $H_2O$ and shows a prominent v wave. Lung auscultation reveals distant breath sounds with prolonged expiration and scattered end-expiratory wheezes. Cardiac examination shows a regular rhythm, a right-sided S3 gallop, and a 3/6 holosystolic murmur at the left lower sternal border that increases with inspiration. The abdomen is distended with shifting dullness, and there is 3+ pitting edema of the lower extremities extending to the thighs.

Laboratory testing reveals the following:
Brain natriuretic peptide (BNP): 650 pg/mL
Thyroid-stimulating hormone (TSH): 1.2 $\mu U/mL$ (normal: 0.4-4.0 $\mu U/mL$)
Free thyroxine (T4): 0.7 ng/dL (normal: 0.9-1.7 ng/dL)
Arterial blood gas (room air): pH 7.32, $pCO_2$ 55 mm Hg, $HCO_3^-$ 28 mEq/L

An echocardiogram shows a normal-sized left ventricle with an ejection fraction of 65%. The left atrium is severely enlarged (volume index 48 mL/m $^2$). The right ventricle is dilated and hypokinetic. Estimated pulmonary artery systolic pressure is 70 mm Hg. Tissue Doppler imaging of the mitral annulus shows an $E/e'$ ratio of 18 (normal $< 8$).

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

A patient presents to the emergency department with a $3$-day history of worsening dyspnea and increased production of purulent, yellow sputum. The patient is $72$ years of age and has documented heart failure with preserved ejection fraction, as well as advanced chronic obstructive pulmonary disease (COPD). His home medications consist of umeclidinium, fluticasone, and lisinopril.

Upon evaluation, he is using accessory muscles to breathe. Vital signs show a temperature of $37.2^\circ$ C ($99.0^\circ$ F), a blood pressure of $145/90$ mm Hg, a heart rate of $112$/min, and a respiratory rate of $26$/min. Pulse oximetry displays $88\%$ on ambient air. Physical examination reveals jugular venous distention up to $8$ cm above the sternal angle. Auscultation of the lungs demonstrates a prolonged expiratory phase with diffuse wheezing and scattered basilar crackles. The patient has trace bilateral pitting edema in the lower extremities.

A Gram stain of the sputum demonstrates numerous polymorphonuclear leukocytes and Gram-positive diplococci.

An arterial blood gas analysis obtained on room air indicates:

A chest radiograph displays hyperinflation and flattened hemidiaphragms but lacks focal consolidations or pleural effusions.

Which of the following represents the most appropriate initial management for this patient?

A 71-year-old woman who resides in a skilled nursing facility is currently receiving care in the intensive care unit for septic shock. She initially presented 48 hours ago with a temperature of 39.2°C (102.6°F), lethargy, and severe hypotension. A chronically encrusted indwelling urinary catheter was identified as the suspected source and immediately removed. Due to her frequent healthcare exposure and risk for multidrug-resistant organisms, empiric antimicrobial therapy was initiated with meropenem and linezolid. She has improved significantly over the past two days, and vasopressor support has been successfully discontinued. Current vital signs are temperature 37.1°C (98.8°F), blood pressure 122/78 mm Hg, pulse 84/min, and respirations 16/min. Finalized results from both blood and urine cultures isolate Proteus mirabilis. Susceptibility testing reveals the organism is resistant to tetracycline but fully susceptible to ampicillin, ceftriaxone, cefepime, piperacillin-tazobactam, and meropenem. Which of the following is the most appropriate pharmacological intervention at this time?

A 62-year-old woman is brought to the emergency department by her family due to a three-day history of productive cough, fever, and progressively worsening shortness of breath. Her past medical history is significant for type 2 diabetes mellitus and essential hypertension. Upon arrival, she appears lethargic and is in marked respiratory distress. Vital signs show a temperature of $38.9^\circ\text{C}$ ($102^\circ\text{F}$), blood pressure of $86/52$ mm Hg, pulse of $124$/min, and respirations of $28$/min. Pulse oximetry indicates an oxygen saturation of $87\%$ on room air. Physical examination demonstrates prominent use of accessory muscles of respiration and coarse crackles over the right lower lung field. Cardiac examination reveals tachycardia with a regular rhythm and no murmurs.

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

A 62-year-old man is recovering in the intensive care unit on day 3 of an admission for acute hypoxemic respiratory failure secondary to severe community-acquired pneumonia. Upon admission, he required endotracheal intubation and mechanical ventilation. Empiric therapy was initiated with intravenous vancomycin and cefepime. Today, his clinical condition has markedly improved; he is afebrile, his oxygenation has stabilized, and he is being evaluated for extubation. Sputum cultures obtained via endotracheal aspirate on admission are now growing Streptococcus pneumoniae. Susceptibility testing demonstrates that the organism is highly sensitive to penicillin, ceftriaxone, and levofloxacin, but resistant to macrolides. Blood cultures from admission have shown no growth. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 35-year-old woman presents to the emergency department with profound weakness in her legs that began earlier today. She reports difficulty standing from a seated position. Her medical history is significant for Sjögren syndrome and recurrent nephrolithiasis. She denies recent diarrhea, vomiting, or changes in her medications. Her temperature is 37.0°C (98.6°F), blood pressure is 110/70 mm Hg, pulse is 88/min, and respiratory rate is 16/min with shallow breaths. Physical examination reveals 2/5 motor strength in the bilateral lower extremities and diminished deep tendon reflexes.

Laboratory results are as follows:

Arterial blood gas on room air:

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

A $42$-year-old woman is evaluated in the surgical step-down unit due to an acute exacerbation of abdominal pain. She was admitted yesterday for a bowel obstruction attributed to adhesions from a previous pelvic surgery. Initial treatment consisted of intravenous hydration, fasting, and placement of a nasogastric tube. Over the past two hours, her symptoms have shifted from colicky and intermittent discomfort to severe, unyielding pain. Vital signs show a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure of $110/68\text{ mmHg}$, heart rate of $122/\text{min}$, and respiratory rate of $24/\text{min}$. Abdominal examination demonstrates marked rigidity, involuntary guarding, and focal rebound tenderness. Blood tests reveal a white blood cell count of $19,500/\text{mm}^3$ with $85\%$ neutrophils and a serum lactate level of $4.5\text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

Paramedics bring a 28-year-old construction worker to the emergency department following a 15-foot (4.5-meter) fall from scaffolding. He is conscious but reports intense pain across his entire abdomen. Vital signs reveal a blood pressure of 82/50 mmHg, a heart rate of 128/min, and a respiratory rate of 24/min. Pulse oximetry is 96% on ambient air. Primary evaluation demonstrates an intact airway with bilateral breath sounds present and equal. No obvious sources of external blood loss are identified. Abdominal examination reveals marked distension, diffuse tenderness, and involuntary guarding. The pelvis is mechanically stable to manual compression. A bedside ultrasound examination (FAST) demonstrates a large anechoic collection in Morison's pouch. Which of the following is the most appropriate next step in management?

A 67-year-old male with a 45-pack-year smoking history is evaluated in the intensive care unit for progressive dyspnea, marked bilateral lower extremity edema, and elevated jugular venous pressure. Echocardiography demonstrates a dilated right ventricle with severe tricuspid regurgitation, but a normal left ventricular ejection fraction. He is diagnosed with severe cor pulmonale secondary to advanced chronic obstructive pulmonary disease (COPD). Arrange the following pathophysiological mechanisms in the correct chronological sequence that led to this patient's current cardiovascular state, starting with the primary respiratory insult.

Select the most appropriate first-line antimicrobial therapy for each of the following patient presentations.

A 2nd-year internal medicine resident is preparing a presentation on inherited and acquired renal tubular disorders. Match each of the following tubulopathies with its primary pathophysiological defect or defining molecular characteristic.

A $52$-year-old man is evaluated by the surgical team for an elevated temperature $28$ hours after undergoing an open partial gastrectomy for a refractory bleeding peptic ulcer. He has a history of type 2 diabetes mellitus and hypertension. His current medications include subcutaneous insulin and intravenous lactated Ringer solution. The patient reports mild, localized pain at the abdominal incision site but denies dyspnea, cough, dysuria, or calf pain. His temperature is $38.4^{\circ}\text{C}$ ($101.1^{\circ}\text{F}$), blood pressure is $135/85\text{ mmHg}$, pulse is $92/\text{min}$, and respirations are $18/\text{min}$. Pulse oximetry shows $96\%$ on room air. Physical examination reveals decreased breath sounds at the lung bases bilaterally, without crackles or wheezes. The abdominal incision is well-approximated, clean, and dry, with no surrounding erythema. His indwelling urethral catheter is draining clear yellow urine at a rate of $45\text{ mL/hour}$. Which of the following is the most appropriate next step in the management of this patient's fever?

A $44$-year-old woman is evaluated in the outpatient clinic due to profound fatigue, generalized muscle cramps, and a $6$-kg ($13.2$-lb) weight gain over the past several months. She reports feeling constantly sluggish and relies on multiple blankets at night despite living in a warm environment. Her medical history is significant for a nonfunctioning pituitary macroadenoma treated with transsphenoidal resection and subsequent adjuvant radiotherapy three years ago. Her blood pressure is $105/65$ mmHg and pulse is $54$/min. Physical examination demonstrates a puffy face and delayed relaxation of the deep tendon reflexes.

Before initiating targeted pharmacotherapy for her thyroid abnormalities, which of the following is the most appropriate next step in management?

Match each clinical presentation of a patient with a suspected hereditary gastrointestinal syndrome to the most accurate diagnosis.

A 24-year-old man with a known history of sickle cell anemia presents to the emergency department reporting acute-onset chest pain, shortness of breath, and a productive cough. His symptoms began 12 hours ago and have progressively worsened. His temperature is $38.6^\circ C$ ($101.5^\circ F$), blood pressure is 110/70 mm Hg, pulse is 118/min, and respiratory rate is 28/min. Oxygen saturation is 88% on room air. Physical examination reveals dullness to percussion and decreased breath sounds over the right lower lung field.

Laboratory evaluation shows:
Hemoglobin: 7.0 g/dL
Leukocyte count: $18,000/mm^3$
Platelet count: $450,000/mm^3$
Reticulocyte count: 14%

Arterial blood gas on room air:
$pH$: 7.48
$PaO_2$: 55 mm Hg
$PaCO_2$: 30 mm Hg

Chest radiograph demonstrates a new right lower lobe consolidation.

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

An $82$-year-old woman arrives at the emergency department accompanied by her daughter. She reports a $3$-day history of progressively worsening, colicky abdominal pain accompanied by multiple episodes of dark green vomiting. The patient mentions she has not passed gas or had a bowel movement for the past $48$ hours. Her past medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and osteoarthritis. Ten years ago, she experienced recurrent episodes of severe postprandial right upper quadrant pain but elected not to undergo surgical intervention. She has never had abdominal or pelvic surgery.

Her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $112/68\text{ mm Hg}$, pulse is $105/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals dry oral mucosa. The abdomen is markedly distended and tympanic to percussion. Auscultation reveals high-pitched, tinkling bowel sounds. There is mild, diffuse abdominal tenderness but no rigidity, guarding, or rebound tenderness. Laboratory studies show a leukocyte count of $11,200/\text{mm}^3$.

A plain radiograph of the abdomen reveals prominently dilated loops of small bowel with multiple air-fluid levels. Additionally, a branching radiolucency is visible overlying the central liver shadow, and a $3.0\text{ cm}$ opaque calcified density is noted in the right lower quadrant.

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

A $65$-year-old male is evaluated in the cardiac intensive care unit for undifferentiated shock. A pulmonary artery catheter is placed to obtain precise hemodynamic measurements. Match the following cardiac conditions with their most characteristic right heart catheterization hemodynamic profile.