All practice questions

A 36-year-old woman arrives at the emergency department reporting three days of progressively worsening, colicky abdominal pain. She has not passed flatus or had a bowel movement during this period. The patient is an avid long-distance runner and has no history of prior abdominal surgeries or significant medical conditions. Her vital signs are temperature 37.3°C (99.1°F), pulse 102/min, respirations 18/min, and blood pressure 118/78 mm Hg. On physical examination, her abdomen is asymmetric, markedly distended, and tympanitic on percussion. Auscultation reveals high-pitched, metallic bowel sounds. Deep palpation elicits diffuse tenderness, but there is no rigidity or rebound tenderness. Laboratory tests demonstrate a leukocyte count of 9,500/mm³ and serum potassium of 3.8 mEq/L. A contrast-enhanced abdominal CT scan reveals a massively dilated, gas-filled cecum displaced into the left upper quadrant, accompanied by a twisting of the mesenteric vessels in the right mid-abdomen. The distal colon is entirely decompressed. Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old man is recently diagnosed with schizophrenia and is currently treatment-naive. Assuming he experiences sequential medication failures due to lack of efficacy at each stage of his treatment, arrange the following management steps in the correct sequential order according to standard pharmacotherapy algorithms.

A 16-year-old boy is brought to the physician by his parents due to behavioral changes and declining school performance over the past three months. The parents report that he has been isolating himself in his bedroom, and they recently discovered a stash of empty computer duster aerosol cans under his bed. When questioned, the patient is evasive, irritable, and refuses to make eye contact. Vital signs are within normal limits. On physical examination, the patient has a mildly broad-based gait and slight dysarthria. An erythematous, eczematous rash is observed surrounding his mouth and nostrils. This patient's current substance use places him at greatest risk for which of the following life-threatening complications?

A 28-year-old man undergoes surgery for acute appendicitis. During the preoperative surgical timeout, the circulating nurse observes that the written informed consent form specifies 'laparoscopic appendectomy,' whereas the electronic operating room schedule indicates 'open appendectomy.' The attending surgeon states that the written consent contains a clerical error and insists that an open approach was verbally agreed upon with the patient. Feeling intimidated by the surgeon's demeanor, the nurse does not escalate the discrepancy, and an open appendectomy is performed. Postoperatively, the patient is distressed by the large abdominal incision, stating he explicitly chose this hospital because he was promised a minimally invasive procedure.

Which of the following is the most appropriate action for the hospital's patient safety committee to take in response to this event?

A 20-year-old female college student is brought to the student health clinic by her roommate due to severe generalized weakness, muscle cramps, and dizziness upon standing. The patient admits to having an intense fear of gaining weight and reveals that she has been using over-the-counter pills to "stay thin", though she refuses to specify the exact medication. Her body mass index is $22 \text{ kg/m}^2$. Vital signs show a blood pressure of 105/65 mm Hg supine and 85/50 mm Hg standing. Pulse is 92/min supine and 118/min standing. Physical examination is unremarkable, with no dental erosions or calluses on her hands. Laboratory studies show:

Sodium: $139 \text{ mEq/L}$
Potassium: $2.6 \text{ mEq/L}$
Chloride: $115 \text{ mEq/L}$
Bicarbonate: $14 \text{ mEq/L}$

Arterial blood gas on room air:
pH: $7.28$
$pCO_2$: $30 \text{ mm Hg}$

Which of the following inappropriate compensatory behaviors is most likely responsible for this patient's laboratory findings?

A 28-year-old male fitness coach presents to the psychiatry clinic with a 5-week history of profound sadness, anhedonia, and sleeping up to 14 hours a day. He reports significant fatigue and difficulty concentrating on his clients' workout plans. Past psychiatric history reveals an episode 3 years ago characterized by 10 days of feeling "invincible," sleeping only 2 hours nightly, and maxing out several credit cards to start an ill-advised supplement company. His medical history is unremarkable. Vital signs are within normal limits. Mental status examination reveals psychomotor retardation, poor eye contact, and a constricted affect. Which of the following pharmacological interventions are appropriate for the acute management of this patient's current episode? (Select all that apply)

A 29-year-old man comes to the primary care clinic for a routine physical examination required by his employer. He works as a night-shift security guard, a job he specifically chose to minimize interaction with others. He is wearing a heavy winter coat despite the hot summer weather, and he has multiple protective amulets around his neck. He speaks in a vague, metaphorical manner, explaining that he can 'feel the auras' of people around him and often senses an invisible 'presence' when alone. However, he denies hearing voices and does not hold any fixed, false beliefs when his thoughts are gently challenged by the physician. He reports having no friends other than his parents. He experiences severe anxiety in social situations, which he attributes to others harboring 'dark energy,' and notes this anxiety does not improve even when he spends more time with people. He states he has been this way since adolescence. Which of the following statements regarding this patient's clinical presentation are correct? (Select 2)

A 58-year-old man is brought to the clinic by his husband due to a 14-month history of progressive behavioral changes. Previously known as a meticulous and empathetic high school teacher, the patient has become increasingly apathetic and frequently makes sexually explicit remarks to neighbors. He recently ate a stranger's sandwich off their plate at a local restaurant and showed no remorse when confronted by the staff. He denies feeling sad or anxious, stating, "Everything is perfectly fine." The patient has a remote history of a single depressive episode in his 20s. He takes over-the-counter diphenhydramine occasionally for sleep but takes no prescription medications. Vital signs are within normal limits. Laboratory studies, including a thyroid-stimulating hormone (TSH) level of 1.2 mU/L and a free T4 of 1.2 ng/dL (normal: 0.8-1.8 ng/dL), are normal. On mental status examination, he has a blunted affect and poor insight, but no delusions or hallucinations are elicited. Montreal Cognitive Assessment (MoCA) score is 23/30; he loses points primarily on clock drawing and verbal fluency tasks, but successfully recalls 3 out of 3 objects after a 5-minute delay. Neurological examination reveals no focal weakness, rigidity, or resting tremor. Which of the following is the most likely diagnosis?

A 28-year-old man is evaluated in the emergency department for a closed fracture of the right radius. He states that he sustained the injury during a physical altercation at a local bar. The patient's pain is well-controlled, and his arm is immobilized in a splint. He is currently awaiting discharge. A police officer arrives at the emergency department, states that the patient is a primary suspect in an aggravated assault investigation, and requests a copy of the patient’s medical evaluation, specifically inquiring if any toxicology screens were performed. The officer does not possess a warrant, a subpoena, or a court order. The patient is awake, alert, and possesses decision-making capacity. Which of the following is the most appropriate response by the physician?

An 78-year-old female resident of an assisted living facility is evaluated in the emergency department for a 3-day history of progressively worsening, crampy abdominal pain and recurrent vomiting of dark green fluid. She has not passed flatus or had a bowel movement for the past 48 hours. Her past medical history includes hypertension, type 2 diabetes mellitus, and intermittent episodes of right upper quadrant postprandial pain for which she has repeatedly declined surgical intervention. Her temperature is 37.4°C (99.3°F), blood pressure is 112/68 mmHg, and pulse is 106/min. Physical examination demonstrates a distended, tympanic abdomen with high-pitched, "tinkling" bowel sounds. There is diffuse, mild abdominal tenderness but no guarding or rebound tenderness. Laboratory studies reveal a leukocyte count of 11,500/mm³ and normal serum lactate. An upright abdominal radiograph demonstrates multiple dilated loops of small intestine with prominent air-fluid levels and branching radiolucent lines overlying the liver shadow. Which of the following is the most appropriate next step in the management of this patient?

A 74-year-old man is hospitalized for the management of melena and severe symptomatic anemia. He has a notable medical history of essential hypertension, type 2 diabetes mellitus, and stage 3 chronic kidney disease. Upon admission, his hemoglobin level is $5.8 \text{ g/dL}$, and he is prescribed three units of packed red blood cells. Approximately 30 minutes into the transfusion of the third unit, the patient reports sudden-onset shortness of breath and a dry cough.

Current vital signs include a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $178/96 \text{ mm Hg}$, heart rate of $115/\text{min}$, and respiratory rate of $26/\text{min}$. Pulse oximetry displays an oxygen saturation of $86\%$ while breathing room air.

Physical examination shows prominent jugular venous distention when the patient is seated at a 45-degree angle. Auscultation of the lungs reveals bilateral basilar crackles without any audible wheezing. Cardiac examination demonstrates a regular tachycardia with a prominent S3 gallop.

An arterial blood gas analysis on room air yields the following results:

pH: $7.28$
PaCO $_2$: $56 \text{ mm Hg}$
PaO $_2$: $52 \text{ mm Hg}$
HCO $_3^-$: $25 \text{ mEq/L}$

A portable chest radiograph displays bilateral pulmonary infiltrates, an enlarged cardiac silhouette, and widening of the vascular pedicle.

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

A 36-year-old woman is brought to the emergency department due to a 6-hour history of sudden, severe, and relentless mid-abdominal pain that radiates to her back. The pain is accompanied by several episodes of retching and non-bilious vomiting. Her medical history is significant for a laparoscopic Roux-en-Y gastric bypass procedure performed three years ago for morbid obesity. She takes no daily medications. Upon arrival, her temperature is 38.4°C (101.1°F), pulse is 128/min, and blood pressure is 88/54 mm Hg after receiving 2 liters of intravenous crystalloids. Physical examination reveals an anxious, diaphoretic patient. The abdomen is slightly distended with marked periumbilical tenderness, striking involuntary guarding, and rebound tenderness. Bowel sounds are absent. Laboratory results demonstrate a leukocyte count of 17,200/mm³ and a serum lactate level of 4.1 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old man arrives at the emergency department following a violent collision during a rugby match. Paramedics report he was struck aggressively in the mid-abdomen by another player's helmet. Upon arrival, he appears pale and lethargic. His temperature is 36.6°C (97.9°F), pulse is 135/min, respirations are 24/min, and blood pressure is 78/45 mm Hg. Pulse oximetry is 95% on room air. The airway is clear, and breath sounds are symmetric bilaterally. Abdominal examination reveals severe distension, diffuse rigidity, and rebound tenderness. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal recess. Which of the following is the most appropriate next step in management?

A 72-year-old woman is evaluated in the outpatient geriatric clinic due to progressive memory impairment and behavioral changes. According to her son, who accompanies her, she has experienced significant day-to-day fluctuations in her alertness and attention over the last 10 months. Furthermore, she frequently describes seeing detailed, silent figures of people standing in her bedroom. Her sleep is often restless, and she frequently shouts and thrashes her arms as if she is acting out her dreams. On physical examination, the patient has a mask-like facial expression, a resting tremor in her left hand, and cogwheel rigidity in both upper extremities. The physician explains the likely diagnosis to the son and discusses management options. The physician strongly cautions against the use of a specific class of medications to treat her perceptual disturbances, noting that it could trigger a severe, potentially fatal reaction characterized by irreversible parkinsonism and autonomic dysfunction. Which of the following medications is most likely to cause the severe reaction described by the physician?

A 38-year-old woman comes to the clinic seeking help to stop drinking alcohol. She reports consuming approximately half a bottle of wine every evening but expresses a strong desire to achieve total abstinence. She has been attending group counseling for the past month and feels motivated, but she requests medication to help manage her daily alcohol cravings. Her medical history is notable for opioid use disorder, which has been in sustained remission for the past 4 years on a stable dose of methadone. She has no other medical conditions. Vital signs are normal. Laboratory studies, including a comprehensive metabolic panel and complete blood count, are within normal limits. Which of the following is the most appropriate pharmacotherapy to promote alcohol abstinence in this patient?

A 68-year-old retired mechanic is brought to the clinic by his wife due to excessive daytime sleepiness and frequent nighttime awakenings over the past two months. His wife reports that he sleeps restlessly and has episodes where he completely stops breathing for about 20 seconds at a time. The patient has a history of a myocardial infarction four years ago, type 2 diabetes mellitus, and hypertension. His current medications include metformin, low-dose aspirin, and amlodipine. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, heart rate 92/min, and respiratory rate 18/min. BMI is $26 \text{ kg/m}^2$. Physical examination reveals a laterally displaced point of maximal impulse, a faint third heart sound (S3), and trace bilateral lower extremity pitting edema. A polysomnography study demonstrates recurrent episodes of apnea without associated chest or abdominal wall movement, occurring between periods of a crescendo-decrescendo breathing pattern. Which of the following is the most appropriate initial step in the management of this patient's sleep disorder?

Emergency medical services transport a 39-year-old unrestrained driver to the trauma bay following a high-speed collision with a concrete barrier. Upon arrival, he is unresponsive and is immediately intubated for airway protection. His heart rate is 142/min and blood pressure is 74/40 mm Hg. Physical examination shows extensive bruising across the sternum. Breath sounds are diminished on the left side. A left-sided chest tube is inserted, yielding 250 mL of gross blood. Bedside ultrasonography (FAST) demonstrates normal cardiac motion without pericardial effusion and no free fluid in the peritoneal cavity. Anteroposterior radiographs of the chest and pelvis are obtained. The pelvic film is unremarkable. The chest radiograph demonstrates a widened mediastinum, obscured aortic contour, and a left apical pleural cap. The patient's hemodynamics do not improve despite the initiation of a massive transfusion protocol. Which of the following is the most appropriate next step in the evaluation of this patient?

A 26-year-old woman is admitted to the medical ward for treatment of a localized methicillin-sensitive Staphylococcus aureus (MSSA) cutaneous abscess on her left forearm, which developed after a superficial self-inflicted laceration. She is currently receiving intravenous vancomycin. Her home medications include fluoxetine. Over the past 48 hours, she has been highly demanding, frequently yelling at nurses for 'ignoring' her, while praising the attending physician as her 'savior.' She has a long-standing history of intense, unstable relationships, chronic feelings of emptiness, and frequent, rapid mood shifts from extreme euphoria to deep dysphoria that last for a few hours, typically triggered by interpersonal conflicts. She reports that after a recent breakup, she heard voices telling her she was worthless for 2 days; this resolved without psychiatric intervention. Today, when told the attending physician is off duty, she becomes enraged, states she is being abandoned, and demands to be discharged immediately. She denies active suicidal ideation. Which of the following is the most appropriate next step in the management of this patient?

A $34$-year-old man is brought to the emergency department after a severe industrial fire. He sustained deep, full-thickness circumferential burns to his anterior and posterior torso, as well as his bilateral lower extremities. The total body surface area burned is estimated at $55\%$. Due to marked oropharyngeal edema and carbonaceous sputum, he was intubated at the scene. Intravenous fluid resuscitation with lactated Ringer solution was initiated based on standard weight-based formulas.

Upon arrival, his temperature is $36.7^\circ\text{C}$ ($98.1^\circ\text{F}$), blood pressure is $112/68 \text{ mm Hg}$, and heart rate is $110/\text{min}$.

Four hours later, the patient's urine output has decreased to $10 \text{ mL/hr}$. Repeat vital signs show a blood pressure of $78/48 \text{ mm Hg}$ and a heart rate of $142/\text{min}$. The mechanical ventilator frequently alarms for high airway pressures.

Current ventilator parameters and central line measurements are as follows:
- Peak inspiratory pressure: $65 \text{ cm H}_2\text{O}$
- Plateau pressure: $55 \text{ cm H}_2\text{O}$
- Central venous pressure: $18 \text{ mm Hg}$

Bedside echocardiography demonstrates a small, underfilled, and hyperdynamic left ventricle. There is no evidence of pericardial effusion. An arterial blood gas analysis reveals a pH of $7.18$, $p\text{CO}_2$ of $72 \text{ mm Hg}$, and $p\text{O}_2$ of $62 \text{ mm Hg}$.

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

A 33-year-old male is transported to the trauma bay by paramedics after sustaining a gunshot wound to the left lower quadrant of his abdomen. On arrival, he appears pale and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 82/50 mm Hg, pulse is 135/min, and respirations are 24/min. Physical examination reveals a single penetrating wound just lateral to the umbilicus. The abdomen is distended, rigid, and diffusely tender to palpation with involuntary guarding. Intravenous access is established and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?