All practice questions

A $62$-year-old woman is evaluated in the emergency department for right-sided flank pain, nausea, and high fever that began $24$ hours ago. Her past medical history is significant for recurrent urinary tract infections. Temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $80/40\text{ mm Hg}$, pulse is $128/\text{min}$, and respirations are $26/\text{min}$. Right costovertebral angle tenderness is present. Laboratory tests show a leukocyte count of $24,000/\text{mm}^3$ with $15\%$ bands and a serum creatinine of $2.3\text{ mg/dL}$. Urinalysis reveals $4+$ leukocyte esterase, positive nitrites, and numerous bacteria. A noncontrast CT scan of the abdomen and pelvis shows a $12\text{-mm}$ calculus obstructing the right proximal ureter with associated severe hydronephrosis. Aggressive intravenous fluid resuscitation and broad-spectrum intravenous antibiotics are initiated, and a norepinephrine infusion is started to maintain mean arterial pressure. Which of the following is the most appropriate next step in management?

A 34-year-old man with moderate-to-severe Crohn disease visits his gastroenterologist to discuss starting a newly approved interleukin-23 (IL-23) inhibitor. The physician reviews the pivotal 52-week clinical trial data with the patient. In this study, $1,000$ adult patients with Crohn disease were equally divided into an experimental arm receiving the IL-23 inhibitor and a control arm receiving a visually matched placebo. By the end of the observation period, $325$ patients receiving the active drug and $200$ patients receiving the placebo had successfully maintained clinical remission. Additionally, the safety analysis revealed that $40$ patients on the active drug experienced a severe upper respiratory tract infection requiring hospitalization, compared to $15$ patients in the placebo group. Based on the data presented, which of the following statements most accurately quantifies the treatment effect and risk of the IL-23 inhibitor over a 52-week period?

A retrospective cohort study uses an international oncology registry to compare the incidence of severe pneumonitis in non-small cell lung cancer patients treated with a novel immune checkpoint inhibitor versus standard platinum-based chemotherapy. The researchers identify a history of heavy tobacco smoking as a significant confounder. Additionally, previous early-phase trials indicate that a patient's baseline pre-existing autoimmune disease status acts as a strong effect modifier for the relationship between the immune checkpoint inhibitor and the development of pneumonitis. The investigators are outlining their final statistical analysis protocol.

Which of the following analytical approaches are most appropriate for managing the variables of smoking history and pre-existing autoimmune disease in this study? (Select all that apply)

A $55$-year-old woman is brought to the emergency department due to severe right flank pain, fever, and chills for the past $24$ hours. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $88/55\text{ mm Hg}$, and pulse is $122/\text{min}$. Laboratory studies show a leukocyte count of $18,000/\text{mm}^3$. A noncontrast computed tomography scan of the abdomen and pelvis reveals a $9\text{-mm}$ obstructing calculus in the right proximal ureter with moderate hydronephrosis and perinephric stranding. Arrange the following management steps in the most appropriate chronological order.

An occupational medicine physician is investigating the long-term respiratory effects of a synthetic resin used in a large manufacturing plant. The physician accesses company employment records and identifies 300 workers who were exclusively assigned to the resin-mixing department between 2010 and 2015. Additionally, 300 workers who were exclusively assigned to the packaging department, where the resin is never handled, are identified from the same time period. The physician then reviews the annual employee health clinic records and spirometry logs from 2015 through 2025 for all 600 workers to determine the incidence of newly diagnosed asthma. Which of the following best describes this study design and the most appropriate primary measure of association to calculate?

A $28$-year-old man comes to the clinic for a routine wellness examination. He has no significant past medical history and takes no medications. He has no symptoms of fatigue, bone pain, abdominal pain, or polyuria. Family history is notable for mild hypercalcemia in his father, who has never required medical or surgical intervention. Vital signs are within normal limits. Physical examination is unremarkable. Laboratory testing reveals the following:

Serum calcium: $11.3\ \text{mg/dL}$ (normal: $8.4\text{--}10.2\ \text{mg/dL}$)
Serum phosphorus: $2.8\ \text{mg/dL}$ (normal: $2.7\text{--}4.5\ \text{mg/dL}$)
Serum creatinine: $0.9\ \text{mg/dL}$
Serum intact parathyroid hormone: $58\ \text{pg/mL}$ (normal: $10\text{--}65\ \text{pg/mL}$)
Serum 25-hydroxyvitamin D: $34\ \text{ng/mL}$ (normal: $20\text{--}50\ \text{ng/mL}$)

Based on the information provided, which of the following is the most appropriate next step in the evaluation of this patient?

A 42-year-old man is brought to the emergency department via helicopter following a structural fire. The injury occurred exactly 2 hours prior to arrival. He weighs $90 \text{ kg}$. Physical examination reveals deep partial-thickness and full-thickness burns involving his entire anterior trunk, his entire right arm, and the entire anterior surface of his right leg. The remainder of his skin is intact. During transport, paramedics administered $480 \text{ mL}$ of intravenous lactated Ringer solution. The trauma team initiates fluid resuscitation using the traditional Parkland formula ($4 \text{ mL} \times \text{weight in kg} \times \% \text{TBSA}$). At what rate (in $\text{mL/hr}$) should the lactated Ringer infusion be set for the remainder of the first 8-hour period following the injury?

A 32-year-old woman presents to the ambulatory care clinic reporting four days of frequent, large-volume, watery stools after returning from an international trip. During the interview, she is noticeably distressed and pacing the room. She states she is terrified of acquiring a severe parasitic infection and has been breathing rapidly for the past hour. Physical examination reveals dry mucous membranes and hyperactive bowel sounds. Vital signs include a heart rate of $112/\text{min}$, blood pressure of $105/65\ \text{mm Hg}$, and respiratory rate of $30/\text{min}$. Laboratory results are as follows:

Serum sodium: $138\ \text{mEq/L}$
Serum potassium: $3.4\ \text{mEq/L}$
Serum chloride: $116\ \text{mEq/L}$
Serum bicarbonate: $12\ \text{mEq/L}$

Arterial blood gas (room air):
pH: $7.38$
$pCO_2$: $21\ \text{mm Hg}$

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

A 64-year-old woman is brought to the emergency department by emergency medical services due to severe, worsening shortness of breath that began 24 hours ago. The patient has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (GOLD stage III). Her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $170/95\text{ mm Hg}$, pulse is $118/\text{min}$, and respirations are $28/\text{min}$. Pulse oximetry shows $86\%$ on room air. She appears in moderate respiratory distress and is using accessory muscles of respiration. Lung auscultation reveals prolonged expiration, diffuse expiratory wheezing, and bilateral crackles at the lung bases. Cardiovascular examination shows distant heart sounds, a normal S1 and S2, and a prominent S3 gallop. The jugular venous pressure is estimated at $13\text{ cm H}_2\text{O}$. There is $2+$ bilateral lower extremity pitting edema.

Laboratory studies show:

Chest radiograph reveals cardiomegaly, bilateral pleural effusions, and cephalization of the pulmonary vasculature. Which of the following is the most appropriate next step in management?

An adolescent girl is brought to the pediatric gynecology clinic by her mother due to the absence of menarche. She is $15$ years and $6$ months old. The patient's mother expresses concern that all of her daughter's peers have already started menstruating. The patient denies cyclical abdominal cramping, pelvic pain, or any prior sexual activity. Her medical history is unremarkable, and she takes no medications. Her height is at the $5$ th percentile for her age, and her weight is at the $25$ th percentile. Vital signs are within normal limits. Physical examination reveals a broad chest with widely spaced nipples and a low posterior hairline. Tanner stage $1$ is noted for breast development, and Tanner stage $2$ for pubic hair. A normal-appearing vaginal introitus is present.

Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient's evaluation, from initial mandatory testing to post-diagnostic screening.

During an evening shift in the emergency department, a $71$-year-old woman is evaluated for a three-day history of progressively worsening dyspnea and increased production of thick, yellowish-green sputum. She has a history of severe chronic obstructive pulmonary disease (COPD), essential hypertension, and osteoarthritis. Her current maintenance medications include a long-acting muscarinic antagonist, a long-acting beta-agonist, and as-needed albuterol.

Vital signs reveal a temperature of $37.6^\circ C$ ($99.7^\circ F$), heart rate of $118/min$, respiratory rate of $28/min$, and blood pressure of $142/85 \text{ mm Hg}$. Oxygen saturation is $86\%$ on room air.

On physical examination, she is in acute respiratory distress and is utilizing accessory muscles of respiration. Jugular venous pressure is visibly elevated at $10 \text{ cm H}_2\text{O}$. Lung auscultation demonstrates prolonged expiration, diffuse expiratory wheezing, and faint bibasilar crackles. She has $2+$ pitting edema in both lower extremities.

Laboratory studies are notable for:
Leukocyte count: $12,500/\mu L$
Brain natriuretic peptide (BNP): $210 \text{ pg/mL}$ (normal $<100 \text{ pg/mL}$)
Thyroid-stimulating hormone (TSH): $1.4 \mu\text{U/mL}$ (normal $0.5-5.0 \mu\text{U/mL}$)
Free T4: $0.5 \text{ ng/dL}$ (normal $0.9-1.7 \text{ ng/dL}$)

Arterial blood gas on room air:
pH: $7.27$
PaO2: $56 \text{ mm Hg}$
PaCO2: $66 \text{ mm Hg}$
HCO3: $29 \text{ mEq/L}$

A chest radiograph shows hyperinflation with flattened diaphragms and enlarged central pulmonary arteries, without focal consolidation.

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

A 48-year-old male construction worker is brought to the emergency department after being crushed between a concrete barrier and a moving vehicle at the level of his hips. On arrival, he is pale, diaphoretic, and confused. Vital signs are blood pressure 75/40 mm Hg, heart rate 138/min, and respiratory rate 24/min. The airway is patent, and breath sounds are clear and equal bilaterally. A portable chest radiograph shows no abnormalities. The abdomen is soft, non-distended, and mildly tender to deep palpation. Anteroposterior compression of the pelvis reveals severe mechanical instability, and a pelvic binder is immediately applied in the trauma bay. A focused assessment with sonography for trauma (FAST) exam demonstrates no anechoic free fluid in the pericardium, hepatorenal recess, splenorenal recess, or retrovesical space. The patient receives 2 units of uncrossmatched type O-negative packed red blood cells and 1 L of isotonic crystalloid. Reassessment reveals a blood pressure of 78/42 mm Hg and a heart rate of 135/min. Which of the following is the most appropriate next step in management?

A 33-year-old gravida 2, para 1 at 39 weeks of gestation is admitted to the labor suite for a trial of labor. Her obstetric history is significant for a previous low transverse cesarean delivery performed due to breech presentation. She is currently in the active phase of labor, with the cervix dilated to 6 cm and the fetal presenting part at 0 station. Her contractions are strong and occur every 3 minutes. The baseline fetal heart rate is 140/min with moderate variability and no decelerations. Thirty minutes later, the patient suddenly reports an excruciating, tearing pain in her lower abdomen that does not resolve between contractions. Her blood pressure decreases to 88/54 mmHg, and her heart rate increases to 122/min. The electronic fetal monitor reveals a sudden, prolonged deceleration to 70/min that has lasted for over 4 minutes. A repeat pelvic examination demonstrates a cervical dilation of 6 cm, but the fetal presenting part is now palpable at -3 station. Moderate dark red vaginal bleeding is noted. Which of the following is the most appropriate immediate next step in management?

Review the clinical situations below. Which ethical principle or legal decision-making standard most appropriately justifies the action taken in each situation?

A 32-year-old woman with a history of systemic lupus erythematosus presents to the clinic with new-onset bilateral lower extremity edema, worsening fatigue, and newly elevated blood pressure of 150/95 mmHg. Recent laboratory studies show worsening normocytic anemia, hypocomplementemia (decreased C3 and C4), and an increasing serum creatinine level from 0.8 mg/dL to 1.6 mg/dL. Arrange the following clinical steps in the most appropriate sequential order for the standard diagnosis and management of this patient's suspected complication.

A 42-year-old woman is brought to the emergency department complaining of sudden-onset, severe, colicky abdominal pain that has become constant over the past 6 hours. She has also experienced multiple episodes of bilious vomiting and has not passed flatus or stool since the pain began. Her medical history is unremarkable, and she has never undergone abdominal surgery. She is an avid long-distance runner. Her temperature is 38.6°C (101.5°F), pulse is 122/min, respirations are 22/min, and blood pressure is 92/58 mm Hg. Physical examination reveals an asymmetrically distended abdomen with a tympanitic mass palpable in the mid-abdomen. There is marked right-sided tenderness with involuntary guarding and rebound tenderness. Laboratory studies show a leukocyte count of $16,500/\mu L$ and a serum lactate of $4.2 \text{ mmol/L}$. An upright plain abdominal radiograph demonstrates a large, comma-shaped dilated bowel loop projecting from the right lower quadrant toward the left upper quadrant, with a paucity of gas in the distal colon. Which of the following is the most appropriate next step in management?

A 62-year-old man is assessed on the surgical ward 72 hours after undergoing an open sigmoid colectomy for complicated diverticulitis. He reports feeling fatigued but denies shortness of breath, chest pain, dysuria, or nausea. He is tolerating a clear liquid diet and passed flatus this morning. His medical history includes chronic obstructive pulmonary disease (COPD) and essential hypertension.

His vital signs are:
Temperature: 38.6°C (101.5°F)
Blood pressure: 132/84 mm Hg
Heart rate: 96/min
Respiratory rate: 18/min
Oxygen saturation: 94% on room air

Physical examination reveals a soft abdomen with mild, localized tenderness at the surgical incision site. There is no rebound tenderness or guarding. The midline incision is well-approximated, clean, and dry without erythema or discharge. Pulmonary auscultation reveals mild, scattered expiratory wheezes bilaterally that are unchanged from his preoperative baseline examination. There are no crackles, and jugular venous distension is absent. His indwelling urethral catheter was removed 24 hours ago, and he has voided spontaneously since then. Bilateral calf examination shows no edema or tenderness.

Which of the following are the most appropriate next steps in the management of this patient? (Select 3)

A 27-year-old male graphic designer is brought to the emergency department by his roommate. The patient has not left his bedroom for the past 3 weeks, has been eating very little, and sleeps up to 14 hours a day. The roommate notes that for the last 5 days, the patient has been repeatedly whispering to himself and claiming that "the authorities have hidden listening devices in the ceiling." Past psychiatric history is notable for an involuntary psychiatric admission 4 years ago due to severe agitation, grandiose beliefs of having superhuman abilities, and pressured speech; that episode lasted 12 days. The patient's medical history is significant for a recent ankle sprain, for which he is currently taking tramadol. Mental status examination reveals a disheveled appearance, poor eye contact, profound psychomotor retardation, and a restricted affect. He confirms hearing a male voice calling him a "traitor." Vital signs are within normal limits. Which of the following is the most appropriate management plan for this patient?

A 26-year-old female dental hygienist comes to the outpatient psychiatry clinic reporting two months of profound sadness, lack of motivation, and sleeping 12 to 14 hours a day. She states she has lost interest in her usual hobbies and feels intense, inappropriate guilt regarding a recent decline in her work performance. She has gained 5 kg (11 lb) over this period. Her medical history is unremarkable, and she currently takes no medications. Vital signs and physical examination are within normal limits. When specifically asked about past mood fluctuations, the patient recalls a distinct five-day period during her sophomore year of college when she felt "supercharged." During that time, she required only 3 hours of sleep per night, started multiple complex art projects, and felt highly productive. That period did not result in hospitalization or significant functional impairment. Mental status examination today reveals a cooperative woman with a blunted affect, psychomotor retardation, and slow speech. She denies suicidal ideation, auditory hallucinations, and paranoia. Which of the following is the most appropriate next step in pharmacotherapy?

A 74-year-old man residing in a skilled nursing facility is evaluated on hospital day $3$ for a complicated urinary tract infection. He was initially brought to the emergency department for altered mental status and a new fever. On admission, his temperature was $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), and his long-term indwelling urinary catheter was found to be obstructed with purulent sediment. The catheter was promptly removed, and he was started empirically on intravenous vancomycin and piperacillin-tazobactam. Today, the patient is afebrile, his mental status has returned to baseline, and he is tolerating an oral diet. Blood cultures obtained on admission show no growth. A urine culture obtained via straight catheterization prior to antibiotic initiation grows $>100,000\text{ CFU/mL}$ of Escherichia coli. Susceptibility testing reveals the organism is susceptible to ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole, but resistant to ampicillin. Which of the following is the most appropriate next step in management?