All practice questions

During a routine follow-up visit, the parents of a 40-day-old infant report an alarming pattern of vomiting that began one week ago. They describe the vomiting as projectile, occurring 10 to 15 minutes after breastfeeding. The vomitus consists solely of undigested milk. Despite the frequent vomiting, the infant exhibits a strong appetite and eagerly attempts to feed again. Upon review of systems, the parents note the infant has had only one wet diaper in the past 24 hours. Vital signs in the clinic show a heart rate of 180/min, a respiratory rate of 32/min, and a blood pressure of 68/38 mm Hg. Physical examination reveals lethargy, a sunken anterior fontanelle, dry oral mucosa, and poor skin turgor. A firm, movable, 2-cm mass is palpated in the right epigastric region. Stat laboratory testing demonstrates the following:

What is the most appropriate initial step in managing this patient's condition?

A 5-week-old male infant is evaluated in the emergency department for persistent vomiting over the past 5 days. His parents report that he forcefully vomits large amounts of milk immediately after every feed. The vomitus does not contain bile or blood. Despite the frequent vomiting, the infant appears extremely hungry and eagerly feeds when offered. He has had only one wet diaper in the last 24 hours. He was born at full term via uncomplicated vaginal delivery. Vital signs show a heart rate of $168 \text{ /min}$, respiratory rate of $30 \text{ /min}$, and blood pressure of $72/40 \text{ mm Hg}$. Physical examination reveals a lethargic infant with sunken eyes, dry mucous membranes, and a depressed anterior fontanelle. Palpation of the abdomen reveals a firm, mobile, $2 \text{-cm}$ mass in the right upper quadrant.

Laboratory studies show:
Sodium: $131 \text{ mEq/L}$
Potassium: $2.8 \text{ mEq/L}$
Chloride: $85 \text{ mEq/L}$
Bicarbonate: $35 \text{ mEq/L}$
Blood urea nitrogen (BUN): $34 \text{ mg/dL}$
Creatinine: $0.8 \text{ mg/dL}$

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

A 68-year-old woman is evaluated in the clinic for a follow-up appointment. Three days ago, she presented to the emergency department with acute left lower quadrant abdominal pain and was diagnosed with uncomplicated diverticulitis based on a computed tomography (CT) scan of the abdomen and pelvis. She was prescribed a course of oral antibiotics, and her abdominal pain is now significantly improving. The CT scan report, however, also noted an incidental finding of an enlarged uterus with a $15\text{ mm}$ thickened endometrial stripe. During the current visit, the patient admits to having experienced two episodes of light vaginal spotting over the past month, which she had initially dismissed. She reached menopause at age 52 and has never used hormone replacement therapy. Her body mass index is $24\text{ kg/m}^2$. Abdominal examination shows resolving mild left lower quadrant tenderness. Pelvic examination reveals a normal-appearing cervix, pale and thinned vaginal mucosa, and no palpable adnexal masses. Which of the following is the most appropriate next step in the management of this patient's gynecologic findings?

A 48-year-old woman comes to the clinic due to a 3-week history of right breast swelling, redness, and heaviness. She is not pregnant and has not lactated in over 15 years. Two weeks ago, she was evaluated at an urgent care clinic for these symptoms, diagnosed with mastitis, and prescribed a 10-day course of oral cephalexin. She completed the antibiotics, but her symptoms have progressively worsened. Her temperature is 37.1°C (98.8°F). Physical examination of the right breast reveals diffuse erythema and significant edema over 60% of the breast surface. The skin has a thickened, pitted appearance resembling an orange peel. Palpation reveals generalized firmness without a discrete, fluctuant mass. There is palpable, firm right axillary lymphadenopathy. Which of the following is the most appropriate next step in management?

During a routine wellness check, a 42-year-old male executive reports feeling constantly "on edge" and exhausted. Upon further questioning, he reveals that for the past 8 months, he has been overwhelmingly worried about various issues including his company's performance, his children's academic success, and his mortgage. He states, "I just can't turn my brain off." He also notes frequent neck stiffness and difficulty falling asleep. He denies any depressed mood, sudden rushes of fear, or repetitive rituals. He drinks one cup of coffee daily and does not use illicit substances. Vital signs are within normal limits. Physical examination shows tense trapezius muscles but is otherwise unremarkable. Thyroid-stimulating hormone (TSH) level is normal. Which of the following is the most likely diagnosis?

An evaluation is requested for a 38-year-old G2P2 woman presenting with progressive right breast enlargement and erythema over the past three weeks. She recently completed a 10-day course of cephalexin for a presumptive diagnosis of mastitis, but her symptoms have worsened. The patient is not pregnant and last breastfed 4 years ago. She has no personal or family history of cancer. Her temperature is 37.1°C (98.8°F), blood pressure is 122/78 mm Hg, and pulse is 76/min. Physical examination reveals a globally swollen, erythematous right breast with prominent skin dimpling and thickening over the dependent portion. A 5-cm firm, ill-defined area of induration is palpated deep to the areola. A 2-cm, hard, mobile lymph node is palpable in the right axilla. Arrange the following steps in the most appropriate sequential order for the diagnostic workup and management of this patient's most likely condition.

A hospital's patient safety committee is analyzing a series of diagnostic errors to improve clinical reasoning training for its medical staff. Match each described clinical scenario with the specific cognitive bias that most likely contributed to the diagnostic error.

For each of the following complex clinical encounters regarding end-of-life care and patient autonomy, identify the most appropriate governing ethical principle or legal framework that validates the physician's chosen course of action.

Healthcare administrators at an integrated health network are evaluating a comprehensive care pathway recently implemented to optimize inpatient flow and clinical safety. The quality improvement task force is monitoring several distinct data points to determine the success and systemic impact of these operational changes. Match each specific metric being tracked by the task force to its appropriate classification within quality improvement measurement frameworks.

A 45-year-old man is evaluated in the emergency department for a deep laceration on his right forearm. He is accompanied by police officers who report finding him intoxicated near the scene of an altercation. During the medical evaluation, the patient becomes highly agitated and repeatedly shouts, "As soon as I get out of here, I'm going to kill my neighbor, John Smith, at 123 Main Street! He's the one who cut me!" The patient is medically stabilized, his laceration is repaired, and he is subsequently placed on an involuntary psychiatric hold due to the credible homicidal threat. He explicitly demands that the physician tell absolutely no one about his statements or his medical treatment. Under standard medical ethics and federal privacy regulations, which of the following disclosures of this patient's protected health information are legally permissible or required without his authorization? (Select all that apply)

A 17-year-old high school student presents to an outpatient community clinic with a 3-day history of dysuria and a purulent urethral discharge. Nucleic acid amplification testing of the urine is positive for Neisseria gonorrhoeae. He is treated with appropriate antimicrobial therapy. During the encounter, the patient expresses significant anxiety about his parents discovering his sexual activity and explicitly requests that they not be informed of his visit. The physician assures him that his privacy will be maintained. The following afternoon, the patient's mother telephones the clinic. She states that she saw a pending clinic charge on her health insurance portal and insists on knowing the medical reason for her son's visit. Which of the following is the most appropriate action by the physician?

A 55-year-old man with a history of severe penicillin allergy is admitted to the medical ward for community-acquired pneumonia. During the admission medication reconciliation process, the admitting resident accurately documents the patient's anaphylactic allergy in the history and physical examination note. However, the resident forgets to enter this critical information into the electronic medical record's (EMR) dedicated allergy tab. The following morning, a cross-covering physician reviews the patient's diagnosis and prescribes intravenous ceftriaxone. Shortly after the first dose is administered, the patient develops a severe anaphylactic reaction requiring epinephrine and a brief transfer to the intensive care unit. The patient fully recovers. During a subsequent departmental review, the chief of medicine recommends placing the cross-covering physician on probationary leave for failing to thoroughly review the admission note prior to placing the medication order. Which of the following is the most appropriate recommendation by the patient safety committee regarding this adverse event?

A 72-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection fraction is brought to the emergency department with worsening shortness of breath and lower extremity edema over the past week. Three days ago, his outpatient physician doubled his daily dose of oral furosemide. On examination, the patient is alert but in mild respiratory distress. Vital signs are: temperature $37.1^\circ\text{C}$, blood pressure $110/70 \text{ mmHg}$, heart rate $95/\text{min}$, and respiratory rate $22/\text{min}$. Pulse oximetry is $89\%$ on room air.

Initial laboratory studies on room air show:

Which of the following is the most accurate assessment of this patient's current acid-base status?

Burn victims often present with complex, life-threatening complications that require immediate recognition and targeted intervention. Match each clinical presentation of a burn or inhalation injury to the most appropriate next step in management or specific antidote.

A 28-year-old surgical resident sustains a deep, bleeding puncture wound to her left index finger from a hollow-bore needle immediately after drawing arterial blood. The source patient is known to be HIV-positive with a high viral load and is concurrently infected with hepatitis C. The resident has previously received the complete hepatitis B vaccine series and has a documented positive surface antibody titer. Arrange the following steps in the most appropriate chronological order for managing this healthcare worker's occupational exposure.

A $64$-year-old woman is evaluated in the hospital on the third day of her admission. She originally presented to the emergency department with a $2$-day history of severe right upper quadrant abdominal pain, jaundice, and a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$). She was diagnosed with acute ascending cholangitis and promptly started on empirical intravenous piperacillin-tazobactam. An emergent endoscopic retrograde cholangiopancreatography (ERCP) was performed, which successfully cleared a $1.2\text{ cm}$ stone from the common bile duct. Today, the patient is completely asymptomatic, afebrile for the past $24\text{ hours}$, and tolerating a regular diet. Blood cultures drawn on admission are now positive for *Escherichia coli*. Susceptibility testing reveals the organism is susceptible to ceftriaxone, ciprofloxacin, and piperacillin-tazobactam, and is resistant to ampicillin. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

During morning rounds, the surgical team evaluates a 48-year-old male patient who is currently on his second day of recovery following an open cholecystectomy for acute gangrenous cholecystitis. The patient complains of new, mild shortness of breath and right-sided abdominal discomfort when attempting to take a deep breath. Vital signs show a temperature of 38.3°C (100.9°F), pulse of 98/min, blood pressure of 128/82 mmHg, and a respiratory rate of 20/min. Pulse oximetry displays 94% on room air. Auscultation of the chest demonstrates diminished breath sounds at both lung bases without crackles or wheezing. The surgical wound appears well-approximated without drainage, induration, or erythema. The abdomen is soft with expected mild tenderness at the incision site.

Which of the following interventions are the most appropriate next steps in managing this patient's clinical presentation? (Select 2 options)

A $65$-year-old man is brought to the emergency department for severe shortness of breath. He has a history of advanced chronic obstructive pulmonary disease (COPD). On arrival, he is in severe respiratory distress with a respiratory rate of $34\text{/min}$ and paradoxical abdominal movement. Arterial blood gas on room air shows a $\text{pH}$ of $7.18$, $\text{PaCO}_2$ of $76\text{ mm Hg}$, and $\text{PaO}_2$ of $48\text{ mm Hg}$. He is urgently intubated and placed on mechanical ventilation. Initial settings are volume assist-control, tidal volume of $450\text{ mL}$, respiratory rate of $18\text{/min}$, $\text{FiO}_2$ of $1.0$, and positive end-expiratory pressure (PEEP) of $5\text{ cm H}_2\text{O}$.

Ten minutes after intubation, the ventilator's high-pressure alarm sounds continuously, and the patient's blood pressure drops precipitously to $70/40\text{ mm Hg}$. His heart rate is $132\text{/min}$. Physical examination reveals prominent jugular venous distention. The trachea is midline, and breath sounds are symmetrically diminished bilaterally with a notably prolonged expiratory phase. Bedside echocardiography demonstrates right ventricular dilation with leftward bowing of the interventricular septum, and a small, underfilled left ventricle.

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

Evaluate the following patient presentations describing varying symptoms of dysphagia and esophageal discomfort. Match each clinical vignette to the most appropriate esophageal diagnosis.

Review the varied clinical presentations and histopathologic findings described below. Match each clinical vignette to the most accurate underlying hereditary gastrointestinal syndrome.