All practice questions

A $64$-year-old woman is evaluated in the primary care clinic due to a $4$-week history of progressive fatigue, generalized weakness, and low-grade fevers. She reports an unintentional weight loss of $3\text{ kg}$ ($6.6\text{ lbs}$) over this period. Her medical history is significant for mitral valve prolapse with regurgitation. Five weeks ago, she underwent a complex root canal procedure. Her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $132/84\text{ mmHg}$, pulse is $82\text{/min}$, and respiratory rate is $14\text{/min}$. Physical examination reveals a well-appearing, comfortable patient. Cardiac auscultation demonstrates a grade $3/6$ holosystolic murmur heard best at the apex and radiating to the axilla. Small, dark red, linear lesions are noted under the nail beds of her right index and middle fingers. The patient is hemodynamically stable without signs of acute heart failure. Three sets of peripheral blood cultures are obtained, and a transesophageal echocardiogram is scheduled. Which of the following is the most appropriate next step in the antimicrobial management of this patient?

A 19-year-old female university student is rushed to the trauma center by helicopter after a high-speed collision while riding an electric scooter. She was not wearing a helmet and struck a concrete barrier. Upon arrival, her airway is clear, and breath sounds are present bilaterally. Vital signs show a blood pressure of 72/40 mm Hg, a heart rate of 144/min, and a respiratory rate of 22/min. Her abdomen is bruised across the lower quadrants, distended, and rigid to palpation. Bedside ultrasonography (FAST) demonstrates a significant accumulation of anechoic fluid in the hepatorenal recess and the rectouterine pouch. A pelvic binder is placed by emergency medical services, and a portable chest radiograph is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old man presents to the clinic for a routine health maintenance examination and preoperative clearance for an upcoming elective inguinal hernia repair. He feels well and reports no cough, dyspnea, hemoptysis, weight loss, or chest pain. He has a 45-pack-year smoking history but quit 2 years ago. A routine preoperative chest radiograph reveals a newly identified $14\text{ mm}$ distinct, rounded opacity in the peripheral right upper lobe.

Assuming the clinical findings at each stage continue to indicate an intermediate-to-high clinical probability of malignancy, arrange the following diagnostic interventions in the most appropriate chronological sequence for evaluating this patient's pulmonary nodule.

A $58$-year-old woman comes to the clinic for a routine evaluation. She has a $15$-year history of type $2$ diabetes mellitus complicated by peripheral neuropathy. The patient reports feeling generally well and denies nausea, vomiting, diarrhea, or shortness of breath. Her current medications include metformin and amlodipine. Blood pressure is $138/84 \text{ mmHg}$ and pulse is $76/\text{min}$. Physical examination shows decreased sensation to monofilament testing on the plantar surfaces of both feet but is otherwise unremarkable.

Laboratory studies reveal the following:
Serum sodium: $140 \text{ mEq/L}$
Serum potassium: $5.6 \text{ mEq/L}$
Serum chloride: $112 \text{ mEq/L}$
Serum bicarbonate: $16 \text{ mEq/L}$
Blood urea nitrogen: $32 \text{ mg/dL}$
Serum creatinine: $1.9 \text{ mg/dL}$
Blood glucose: $148 \text{ mg/dL}$
Urine pH: $5.2$

Which of the following best describes the primary underlying pathogenesis of this patient's acid-base and electrolyte findings?

A 35-year-old woman with a history of systemic lupus erythematosus presents to the clinic with progressive muscle weakness and fatigue over the past 2 weeks. She denies any recent illnesses, diarrhea, or vomiting. Current medications include hydroxychloroquine. Vital signs are within normal limits. Laboratory testing reveals the following:

What is this patient's calculated urine anion gap?

A 34-year-old woman is brought to the emergency department by her husband due to severe agitation, confusion, and palpitations. She has a history of Graves disease but stopped taking her antithyroid medications three months ago. Her temperature is 39.4°C (103°F), blood pressure is 160/70 mmHg, and heart rate is 145/min and irregular. Physical examination reveals a staring gaze, a diffusely enlarged and non-tender thyroid gland, diaphoresis, and a fine tremor. An electrocardiogram shows atrial fibrillation with rapid ventricular response. A clinical diagnosis of thyroid storm is made. Arrange the following management steps in the correct chronological sequence for this patient, from immediate acute management to long-term definitive therapy.

A $58$-year-old woman comes to the outpatient clinic reporting a $5$-month history of frequent, foul-smelling, bulky stools accompanied by severe abdominal bloating and progressive fatigue. Her medical history is significant for diffuse cutaneous systemic sclerosis. Vital signs are normal. Physical examination shows thickened, tight skin over the face and fingers, as well as decreased vibratory sensation in the distal lower extremities bilaterally. Abdominal examination reveals mild distension with tympany but no tenderness or guarding. Laboratory evaluation shows a hemoglobin concentration of $9.1 \text{ g/dL}$ and a mean corpuscular volume of $115 \text{ fL}$. Serum vitamin $B_{12}$ levels are markedly reduced, while serum folate concentration is significantly elevated above the reference range. Which of the following is the most appropriate next step in the diagnostic or therapeutic management of this patient?

An emergency medical response team evaluates a 64-year-old man at the hospital's triage bay who complains of severe, progressively worsening breathlessness over the last 48 hours. He also notes a new onset of greenish-yellow sputum production and an increased frequency of coughing. His past medical history is notable for severe emphysema, type 2 diabetes mellitus, and a 45-pack-year smoking history.

Vital signs on arrival are:
Temperature: 37.8°C (100.0°F)
Heart rate: 108/min
Blood pressure: 152/92 mm Hg
Respiratory rate: 26/min
Oxygen saturation: 85% on room air

Physical examination demonstrates significant use of accessory muscles of respiration. Auscultation reveals a prolonged expiratory phase and widespread bilateral expiratory wheezing with overall decreased air movement. Cardiovascular examination shows regular tachycardia with no murmurs, gallops, or jugular venous distention. There is no lower extremity edema.

Arterial blood gas (ABG) analysis on room air reveals:
pH: 7.26
PaCO2: 65 mm Hg
PaO2: 52 mm Hg
HCO3-: 29 mEq/L

A bedside chest radiograph displays hyperinflated lung fields and flattened diaphragms, without evidence of focal opacities, pleural effusions, or cardiomegaly.

Which of the following interventions are appropriate for this patient's current condition? (Select all that apply)

A 65-year-old man is evaluated in the hospital on day 4 of admission for infective endocarditis. He initially presented with a 2-week history of fatigue, low-grade fever, and a new holosystolic murmur at the cardiac apex. A transthoracic echocardiogram obtained on admission demonstrated a $1.2$-cm vegetation on the posterior leaflet of the mitral valve with moderate mitral regurgitation. Empiric therapy with intravenous vancomycin and ceftriaxone was initiated. Today, final blood culture results from admission show growth of *Streptococcus gallolyticus* (formerly *Streptococcus bovis*) in all four bottles. Susceptibility testing confirms the organism is highly susceptible to penicillin (minimum inhibitory concentration $\leq 0.12$ $\mu$ g/mL) and ceftriaxone. The patient is currently afebrile and hemodynamically stable. His renal function is normal, and he has no known drug allergies.

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

Match each clinical presentation of blunt pelvic and genitourinary trauma with the most appropriate next step in management or diagnosis.

A $54$-year-old man is brought to the emergency department by his partner due to a severe headache, subjective fever, and progressive lethargy over the past $24$ hours. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $142/88$ mmHg, pulse is $112$/min, and respirations are $20$/min. Physical examination demonstrates marked resistance to passive neck flexion. Neurologic examination reveals somnolence, disorientation to place and time, and a pronounced right-sided pronator drift with right lower extremity weakness. Arrange the following interventions in the most appropriate sequential order for this patient's management.

An outpatient evaluation is requested for a $58$-year-old woman experiencing progressively worsening fatigue, subjective weakness, and severe constipation over the past $6$ months. She also reports a $4$-kg ($8.8$-lb) weight gain during this time despite a notably poor appetite. She has no significant past medical history and takes no over-the-counter or prescription medications. Vital signs show a temperature of $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$), blood pressure of $105/65\text{ mm Hg}$, and a heart rate of $58\text{/min}$. Physical examination reveals dry, cool skin and a markedly delayed relaxation phase of the deep tendon reflexes.

Laboratory studies are obtained:
Thyroid-stimulating hormone (TSH): $1.8\text{ mU/L}$ (Normal: $0.5$ - $5.0\text{ mU/L}$)
Free thyroxine (T4): $0.4\text{ ng/dL}$ (Normal: $0.9$ - $1.7\text{ ng/dL}$)

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

A 68-year-old man is brought to the emergency department due to the sudden onset of crushing substernal chest pain, severe diaphoresis, and profound dizziness that began an hour ago. His past medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus. His current blood pressure is 78/50 mm Hg, and his heart rate is 55/min. Respirations are 22/min, and oxygen saturation is 96% on room air. Physical examination reveals clear lungs bilaterally with no crackles or wheezes. The jugular veins are markedly distended. A standard 12-lead electrocardiogram demonstrates 3-mm ST-segment elevations in leads II, III, and aVF, along with reciprocal changes in leads I and aVL.

Arrange the following management steps in the most appropriate chronological sequence for the diagnostic evaluation, hemodynamic stabilization, and definitive treatment of this patient's condition.

A 51-year-old woman is brought to the emergency department complaining of sudden-onset, severe, and unremitting abdominal pain for the past 6 hours. She has vomited bilious material twice since the pain began. Her surgical history is notable for a total abdominal hysterectomy performed five years ago for uterine fibroids. On presentation, her temperature is 38.3°C (100.9°F), heart rate is 118/min, and blood pressure is 105/65 mm Hg. Physical examination shows a significantly distended abdomen with focal rigidity and pronounced rebound tenderness in the left lower quadrant. Bowel sounds are absent. Laboratory results reveal a leukocyte count of 16,500/mm³ and a serum lactate level of 3.2 mmol/L. A CT scan of the abdomen and pelvis with intravenous contrast demonstrates a transition point in the distal jejunum, poor enhancement of the bowel wall distal to the transition point, a mesenteric "whirl" sign, and moderate free pelvic fluid. Which of the following is the most appropriate next step in management?

Emergency medical responders bring a 19-year-old man to the hospital after he was discovered unresponsive in his university dormitory. His roommate reports that the patient has type 1 diabetes mellitus and has been struggling with depression, recently experimenting with unprescribed oxycodone. On arrival, his temperature is 36.8°C (98.2°F), blood pressure is 105/65 mm Hg, pulse is 114/min, and respirations are 8/min. Physical examination reveals a somnolent patient with shallow breathing, dry mucous membranes, and pinpoint pupils.

Laboratory results are as follows:
Serum sodium: 140 mEq/L
Serum potassium: 4.8 mEq/L
Serum chloride: 102 mEq/L
Serum bicarbonate: 12 mEq/L
Blood glucose: 480 mg/dL
Blood urea nitrogen: 28 mg/dL
Serum creatinine: 1.3 mg/dL

Arterial blood gas analysis on room air:
pH: 7.12
PaCO2: 38 mm Hg
PaO2: 60 mm Hg

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

Match the following Hepatitis B serological and biochemical profiles to their most accurate clinical status.

A 41-year-old man is brought to the emergency department after a motorcycle collision. He is unresponsive but opens his eyes to painful stimuli. Vital signs are temperature $36.2^\circ\text{C}$, blood pressure $78/48 \text{ mm Hg}$, heart rate $132/\text{min}$, and respiratory rate $24/\text{min}$. The airway is patent, and breath sounds are equal bilaterally. A properly positioned pelvic binder was placed by emergency medical services. Extended focused assessment with sonography for trauma (eFAST) demonstrates no intraperitoneal fluid and no pericardial effusion. There is normal lung sliding bilaterally. An anteroposterior pelvic radiograph reveals a severe diastasis of the pubic symphysis and a right sacroiliac joint disruption. After receiving $1\text{ L}$ of warmed intravenous crystalloids and $2\text{ units}$ of uncrossmatched type O-negative blood, the patient's blood pressure is $82/50 \text{ mm Hg}$ and heart rate is $128/\text{min}$. Which of the following is the most appropriate next step in management?

A 59-year-old woman is brought to the emergency department by her family due to a 3-day history of progressively worsening shortness of breath, right-sided chest discomfort, and a productive cough with rust-colored sputum. She has a past medical history of advanced chronic obstructive pulmonary disease (COPD) and essential hypertension. Her current home medications include a daily fluticasone-salmeterol inhaler and amlodipine. On arrival, she appears in moderate respiratory distress, utilizing accessory muscles of respiration but remains fully alert and cooperative.

Temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $138/82\text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry reveals an oxygen saturation of $87\%$ on room air.

Physical examination shows a jugular venous pressure of $6\text{ cm H}_2\text{O}$. Auscultation of the lungs reveals a prolonged expiratory phase with diffuse expiratory wheezing, as well as coarse crackles and bronchial breath sounds localized to the right lower lung base. Cardiac examination shows a regular tachycardia without murmurs or gallops. There is no lower extremity edema.

Laboratory results:
- Leukocyte count: $16,500/\text{mm}^3$ (with $85\%$ segmented neutrophils)
- Brain natriuretic peptide (BNP): $45\text{ pg/mL}$

Arterial blood gas (on room air):
- pH: $7.24$
- PaCO $_2$: $70\text{ mmHg}$
- PaO $_2$: $52\text{ mmHg}$
- HCO $_3^-$: $29\text{ mEq/L}$

A sputum Gram stain shows abundant polymorphonuclear leukocytes and numerous Gram-positive, lancet-shaped diplococci. A chest radiograph demonstrates hyperinflated lung fields, flattened diaphragms, and a dense alveolar consolidation in the right lower lobe.

Which of the following interventions should be included in the immediate management bundle for this patient? (Select all that apply)

Match each valvular heart disease with its most characteristic constellation of physical examination findings.

Match each of the following serum laboratory profiles with the most likely underlying endocrinologic diagnosis.