All practice questions

A 55-year-old man comes to the clinic due to a 4-week history of progressive abdominal swelling, early satiety, and lower extremity edema. He has a 15-year history of heavy alcohol consumption but stopped drinking one month ago. His temperature is 37.0°C (98.6°F), blood pressure is 112/68 mm Hg, and pulse is 88/min. Physical examination reveals scleral icterus, multiple spider angiomas on the upper chest, and shifting dullness on abdominal percussion. Trace pitting edema is present bilaterally in the lower extremities. A diagnostic paracentesis is performed.

What is the primary pathophysiologic mechanism responsible for this patient's abdominal fluid accumulation?

A 67-year-old man visits his primary care physician for a routine health maintenance examination. He has no active complaints. His past medical history includes hypertension and hyperlipidemia, both well-controlled on daily medications. He smoked one pack of cigarettes daily from age 20 to age 50 but successfully quit 17 years ago. He drinks alcohol occasionally. Vital signs are within normal limits. Physical examination, including a careful abdominal examination, is unremarkable. A review of his medical records reveals he has not received any preventive screening for abdominal conditions. Which of the following is the most appropriate recommendation regarding screening for an abdominal aortic aneurysm in this patient?

Following 8 hours of severe, crampy abdominal pain and repeated bilious vomiting, a 61-year-old man arrives at the emergency department. He reports absolute constipation and an inability to pass flatus since the symptoms commenced. His surgical history is notable for an open appendectomy performed 15 years ago. The patient takes lisinopril for hypertension. His temperature is 37.2°C (99.0°F), pulse is 78/min, respirations are 16/min, and blood pressure is 134/82 mm Hg. Cardiopulmonary examination is unremarkable. The abdomen is significantly distended and tympanic to percussion. Auscultation reveals high-pitched, tinkling bowel sounds. Palpation elicits mild, diffuse tenderness without guarding, rigidity, or rebound. Laboratory studies show a leukocyte count of 8,500/mm³ and a serum lactate level of 1.1 mmol/L. Intravenous fluid resuscitation is initiated. A contrast-enhanced CT scan of the abdomen and pelvis demonstrates multiple dilated loops of small bowel measuring up to 4.5 cm in diameter. There is a specific transition point in the right lower quadrant where a clustered, U-shaped configuration of fluid-filled bowel loops is seen, with engorged mesenteric vessels radiating toward a single central point. The large intestine is entirely decompressed. Which of the following is the most appropriate next step in the management of this patient?

A 38-year-old woman is evaluated in the neurology clinic for progressive choreiform movements, irritability, and cognitive decline. Her biological father passed away from a similar neurological condition, although she has had little contact with that side of her family. Genetic testing confirms the diagnosis of Huntington disease. During the consultation, the patient becomes tearful. She tells the physician, "My 34-year-old brother is getting married next month and they plan to start a family immediately. He doesn't know about our father's medical history because he was raised by a different family member. I can't bear to ruin this happy time for him. You must promise me you won't tell him." Which of the following is the most appropriate response?

Match each specific patient clinical scenario with the most appropriate immunization management strategy based on current CDC/ACIP guidelines.

A 42-year-old woman is being treated by a psychiatrist for major depressive disorder and alcohol use disorder. She is currently involved in a contentious child custody dispute with her ex-husband. The psychiatrist receives a subpoena duces tecum by certified mail from the ex-husband's attorney, demanding the production of the patient's complete medical records, including all psychotherapy notes. The subpoena is signed by the ex-husband's attorney and a local court clerk. However, there is no accompanying signature from a judge, and no release of information form signed by the patient is attached. The document states that the psychiatrist must comply within 7 days or face legal penalties. Which of the following is the most appropriate next step?

Match each clinical presentation of acute genitourinary trauma with the most appropriate immediate diagnostic or therapeutic next step.

A 34-year-old woman is brought to the trauma bay via ambulance after being ejected from a rolling vehicle. Paramedics report she has been unresponsive since their arrival 20 minutes ago and intubated her at the scene. Current vital signs include a temperature of 36.2°C (97.2°F), blood pressure of 72/40 mm Hg, heart rate of 145/min, and respiratory rate of 28/min. Neurological evaluation reveals a Glasgow Coma Scale score of 3T. Her right pupil is 7 mm and unreactive to light; the left pupil is 3 mm and briskly reactive. Physical examination is notable for a large, actively bleeding laceration with a palpable step-off over the right temporal bone, as well as a tensely distended, rigid abdomen. Intravenous access is established, and a rapid infusion of 2 L of warmed crystalloid does not improve her blood pressure. Which of the following is the most appropriate next step in the management of this patient?

A $62$-year-old man comes to the urology clinic reporting a dull, aching heaviness in his left scrotum that has gradually worsened over the past $3$ months. He denies any dysuria, urethral discharge, fever, or history of sexually transmitted infections. His medical history includes hypertension and a $30$-pack-year history of smoking. Vital signs are within normal limits. Physical examination of the patient in the standing position reveals a palpable, non-tender, tortuous, "bag of worms" mass superior to the left testicle. When the patient is placed in the supine position, the scrotal mass does not decompress or reduce in size. Urinalysis shows $15$ red blood cells per high-power field, but is negative for leukocyte esterase and nitrites. Which of the following is the most appropriate next step in management?

A research group is investigating the association between a newly approved anti-obesity medication and the incidence of acute cholecystitis. In an initial prospective observational cohort study, the crude relative risk of acute cholecystitis in patients taking the new medication compared to those on standard lifestyle interventions is 2.2 (95% CI: 1.6-2.9).

During data review, the investigators observe that the new medication was disproportionately prescribed to patients with a baseline body mass index (BMI) > 40 kg/m². They subsequently stratify the data by baseline BMI. In the stratum of patients with a BMI > 40 kg/m², the relative risk is 1.1 (95% CI: 0.8-1.5). In the stratum of patients with a BMI ≤ 40 kg/m², the relative risk is also 1.1 (95% CI: 0.9-1.4).

The research group is now planning a subsequent observational cohort study to further investigate this relationship. They want to ensure that baseline BMI does not distort the association, and they specifically wish to address this issue during the design phase of the new study.

Which of the following methods is most appropriate to achieve this goal?

A 38-year-old man is admitted to the general medical ward for treatment of community-acquired pneumonia. His medical record clearly documents a severe allergy to penicillin. Despite this, the admitting physician prescribes intravenous amoxicillin-clavulanate. The floor nurse, who is covering multiple extra patients due to an unexpected staffing shortage, administers the medication without checking the patient's allergy identification band. Ten minutes later, the patient develops a diffuse urticarial rash and wheezing, which is promptly treated with epinephrine. A subsequent review reveals that the electronic health record (EHR) medication allergy alert system had been inadvertently disabled globally during a hospital-wide software update three days prior. Which of the following represents a latent error in this clinical scenario?

An emergency medicine physician is evaluating a 68-year-old man who presents with pleuritic chest pain and shortness of breath. The physician decides to order a D-dimer assay to help rule out a pulmonary embolism. The laboratory recently updated its reporting system: instead of using a uniform threshold of $500 \text{ ng/mL}$ for all patients, it now applies an age-adjusted threshold (calculated as $\text{age} \times 10 \text{ ng/mL}$) for individuals over 50 years of age. For this patient, a result is now considered positive only if it exceeds $680 \text{ ng/mL}$. Compared to the previous uniform standard, how does implementing this higher threshold affect the diagnostic performance of the D-dimer test in the demographic of patients older than 50?

A physician is evaluating a $68$-year-old man in the hospital who was admitted $36$ hours ago for crampy abdominal pain, obstipation, and vomiting. He has a history of an open appendectomy $20$ years ago. On admission, plain abdominal radiographs demonstrated dilated loops of small intestine with multiple air-fluid levels and a paucity of colonic gas. He was initially managed with intravenous fluid resuscitation, bowel rest, and nasogastric tube decompression. Over the last two hours, the patient reports that his abdominal pain has transitioned from intermittent cramping to a severe, constant ache. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $96/60\text{ mmHg}$, pulse is $118\text{/min}$, and respiratory rate is $22\text{/min}$. Physical examination reveals a markedly distended abdomen with involuntary guarding and rebound tenderness in the periumbilical region. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ with $12\%$ bands, and a serum lactate level of $4.2\text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman, gravida 1 para 0, at 32 weeks gestation is evaluated in the labor and delivery unit for severe headaches, visual changes, and a blood pressure of 170/110 mm Hg. She is diagnosed with severe preeclampsia. Continuous fetal monitoring indicates repetitive late decelerations, strongly suggesting fetal distress. The obstetrician recommends an urgent cesarean delivery to prevent maternal complications and fetal demise. The patient is awake, alert, and oriented. She accurately restates the severity of her condition, including the high likelihood of fetal death and maternal seizures if surgery is not performed. However, she states, "I have always wanted a natural birth, and I absolutely refuse to have surgery under any circumstances." Her husband is at the bedside and demands that the physician perform the surgery immediately to save the baby. Which of the following is the most appropriate next step in management?

Match each postoperative clinical presentation with the most likely diagnosis and its appropriate initial management.

A 66-year-old woman is evaluated at an ambulatory clinic as a new patient. She recently lost her health insurance and has not received comprehensive medical care for the past two years. She has a history of essential hypertension, for which she takes amlodipine. She underwent natural menopause at age 52. During the review of systems, the patient mentions that two months ago she experienced three days of light vaginal bleeding, which she attributed to "normal changes of aging." The bleeding has not recurred. She has a 45 pack-year smoking history and currently smokes one pack of cigarettes daily. Her father died of a ruptured abdominal aortic aneurysm at age 75. A review of her records shows a normal screening colonoscopy and negative cervical human papillomavirus (HPV) testing performed at age 64. She recently received a normal screening mammography and an updated influenza vaccine at a local health fair. Vital signs show a blood pressure of 136/84 mm Hg, heart rate of 76/min, and body mass index (BMI) of 29 kg/m $^2$. Physical examination, including a pelvic examination, is unremarkable with no active bleeding. Which of the following sets of diagnostic and screening tests is the most appropriate next step in the management of this patient?

A 79-year-old man is brought to the emergency department by his daughter due to a 2-day history of worsening confusion and right-sided weakness. He had a mechanical fall approximately one month ago but did not seek medical attention at the time. His past medical history is significant for permanent atrial fibrillation, for which he takes warfarin and metoprolol. On examination, the patient is somnolent but arouses to verbal stimuli. His blood pressure is 155/90 mmHg, and heart rate is 78/min. Neurologic examination reveals a left-sided pupil that is sluggishly reactive to light and right-sided hemiparesis. Laboratory studies show an international normalized ratio (INR) of 2.8. A non-contrast computed tomography (CT) scan of the head demonstrates a large, crescent-shaped, hypodense extra-axial fluid collection over the left cerebral hemisphere with a 13-mm midline shift. Which of the following is the most appropriate next step in management?

A hospital's quality improvement committee is reviewing recent incident reports to improve patient safety. During the review, they analyze a near-miss event in which an infant was almost given intravenous acyclovir after a triage nurse misinterpreted neonatal cephalic pustulosis as a serious infectious rash. They also review an adverse event where a 45-year-old man with a documented severe penicillin anaphylaxis allergy received intravenous piperacillin-tazobactam. Root cause analysis of the second event reveals that the physician was experiencing alert fatigue and bypassed the electronic health record (EHR) warning. The committee decides to prioritize systemic interventions to prevent the medication error from recurring. Which of the following proposed interventions is most likely to be effective?

Match each clinical and radiographic vignette with the most likely primary bone tumor diagnosis.

A $38$-year-old man presents to the clinic complaining of episodic headaches, excessive sweating, and a feeling of a rapid heart rate. His blood pressure in the clinic is $172/105 \text{ mmHg}$. He reports that these "spells" have been occurring once or twice a week for the past $3$ months. Physical examination is otherwise unremarkable. Laboratory evaluation reveals a serum potassium of $4.2 \text{ mEq/L}$ and fasting blood glucose of $115 \text{ mg/dL}$. A $24$-hour urine collection shows fractionated metanephrines that are $4$ times the upper limit of normal. Contrast-enhanced CT of the abdomen reveals a $4.5 \text{ cm}$ well-circumscribed, lipid-poor mass in the right adrenal gland. The patient is scheduled to undergo a laparoscopic right adrenalectomy in $3$ weeks. Which of the following is the most appropriate preoperative pharmacological sequence to prevent perioperative complications?