All practice questions

Emergency medical personnel transport a $61$-year-old male to the hospital shortly after he experienced the sudden onset of severe, crushing retrosternal chest pain. The pain began while he was resting and is accompanied by profound diaphoresis. His medical history includes type 2 diabetes mellitus, hyperlipidemia, and a $35$ pack-year smoking history. Upon arrival, he appears pale and lethargic. Vital signs demonstrate a blood pressure of $84/52$ mmHg and a heart rate of $56$/min. Physical examination reveals prominent distention of the jugular veins when the patient is positioned at a $45^\circ$ angle. Auscultation of the chest demonstrates completely clear lung fields bilaterally. Cardiac auscultation reveals bradycardia but no murmurs, rubs, or gallops. An electrocardiogram is rapidly obtained and shows $3$-mm ST-segment elevations in leads II, III, and aVF, along with reciprocal ST-segment depressions in leads I and aVL. Which of the following is the most appropriate initial intervention to address this patient's hemodynamic state?

A 42-year-old woman comes to the clinic reporting significant weight gain, worsening fatigue, and the development of dark hair on her face and chest over the past 8 months. Her medical history is unremarkable, and she takes no medications. On physical examination, her blood pressure is 160/100 mm Hg. She has a rounded face with plethora, truncal obesity with prominent supraclavicular fat pads, and several wide, purplish striae on her abdomen. Proximal muscle weakness is noted when she attempts to stand from a seated position. The physician suspects endogenous hypercortisolism. Assuming each step's result dictates the need for the subsequent one in a classic ACTH-dependent pathway, arrange the following diagnostic steps in the most appropriate chronological order.

A 19-year-old man comes to the university health clinic due to a painful swelling in his right axilla that has been worsening over the past 4 days. He is a collegiate wrestler and reports that several of his teammates have recently been treated for similar skin lesions. He has no significant past medical history and takes no medications. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mm Hg, pulse 74/min, and respirations 14/min. Physical examination shows a 3.5-cm, exquisitely tender, erythematous, and fluctuant nodule in the right axilla. There is no surrounding induration or erythema extending beyond the nodule, and no regional lymphadenopathy is appreciated. Which of the following is the most appropriate next step in management?

A 42-year-old woman is evaluated in the emergency department for severe, colicky left flank pain radiating to the groin and gross hematuria. For the past year, she has experienced progressive generalized muscle weakness, persistent dry eyes, and a dry mouth. Blood pressure is 120/76 mm Hg, and pulse is 88/min. Laboratory studies show:

A non-contrast CT of the abdomen and pelvis reveals a 5-mm calculus in the left ureter and bilateral medullary nephrocalcinosis. Which of the following is the most likely primary pathophysiologic mechanism responsible for this patient's laboratory and imaging findings?

A $72$-year-old man is evaluated in the intensive care unit due to abnormal laboratory results. He was admitted $8$ days ago for severe sepsis secondary to complicated pyelonephritis, which required intravenous antibiotics and vasopressor support. He has steadily improved; vasopressors were discontinued $3$ days ago, and he is currently breathing comfortably on room air. He has a medical history of type $2$ diabetes mellitus and benign prostatic hyperplasia. His temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), blood pressure is $130/80\text{ mm Hg}$, and pulse is $78\text{/min}$. Physical examination shows a tired-appearing man. His neck is supple with no thyromegaly or palpable nodules. Laboratory studies show:

Which of the following is the most appropriate next step in the management of this patient's thyroid findings?

An expectant mother at 37 weeks of gestation presents to the triage unit complaining of profound, full-body itching that has progressively worsened over the last week. The sensation is particularly unbearable at night and is concentrated on the palms of her hands and the soles of her feet. She has no prior history of dermatologic conditions, and no visible rash or lesions are observed on physical examination. Her blood pressure is 118/76 mm Hg, and her temperature is 37.1°C (98.8°F).

Laboratory results are as follows:

A continuous fetal heart rate tracing reveals a baseline of 140/min, moderate variability, and periodic shallow decreases in the heart rate that begin and end exactly symmetrically with the patient's spontaneous mild uterine contractions.

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

A corporate medical director at a large manufacturing facility is investigating a cluster of employees who presented with high fever, cough, coryza, conjunctivitis, and a descending maculopapular rash. The initial cluster of three employees developed symptoms between April 2 and April 4. A subsequent cluster of five employees developed symptoms between April 14 and April 17. No other employees reported symptoms between April 5 and April 13. The suspected pathogen transmits via airborne respiratory particles and has a typical incubation period of 10 to 14 days. Several exposed coworkers, who are in their second trimester of pregnancy and lack immunity to the suspected pathogen, had documented close face-to-face contact with the second cluster of employees two days ago. They are currently asymptomatic. Which of the following represents the most accurate epidemiological classification of this outbreak pattern and the most appropriate immediate intervention for the pregnant coworkers?

An $82$-year-old male is evaluated in the surgical ward on postoperative day $8$ following an open sigmoid colectomy for recurrent diverticulitis. Over the past $24$ hours, he has developed worsening, severe abdominal pain and multiple episodes of bilious emesis. He has not passed flatus or stool for two days. His temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $132/\text{min}$, and respiratory rate is $26/\text{min}$. The patient is lethargic and diaphoretic. Abdominal examination reveals a markedly distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. The surgical incision is clean with no surrounding erythema or purulent drainage.

Laboratory studies show:
Leukocyte count: $24,000/\text{mm}^3$
Serum lactate: $6.2\text{ mmol/L}$
Bicarbonate: $12\text{ mEq/L}$

Arterial blood gas (room air):
pH: $7.21$
pCO $_2$: $29\text{ mm Hg}$
pO $_2$: $80\text{ mm Hg}$

Supine and upright abdominal radiographs display multiple dilated loops of small bowel with air-fluid levels and an absence of colonic gas. Aggressive intravenous fluid resuscitation is initiated.

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

A 42-year-old man is hospitalized for a severe depressive episode in the context of bipolar disorder. His home medications, which include phenelzine, are documented in a separate, minimally visible tab within the hospital's electronic health record (EHR). During an overnight shift, a cross-covering resident evaluates the patient for worsening depressive symptoms. Due to the fragmented EHR interface, the resident does not see the home medication list and prescribes citalopram. Several hours later, the patient develops diaphoresis, tachycardia, hyperreflexia, and clonus. He is transferred to the intensive care unit for management of serotonin syndrome and fully recovers. Which of the following is the most appropriate quality improvement action to prevent similar incidents in the future?

A 26-year-old woman, gravida 2, para 1, at 24 weeks gestation comes to the clinic for a routine prenatal visit. She has a history of severe opioid use disorder but had been in remission for two years. During the confidential portion of the interview, she tearfully admits that she relapsed and has been injecting fentanyl for the past two weeks. She explicitly asks the physician not to disclose this information to anyone, stating, "If you tell the authorities, they will take my 4-year-old son away, and I will end up in jail. Please just help me stop." She denies any thoughts of self-harm or harming her son. She reports that her son is currently being cared for by her mother while she seeks help. Fetal ultrasound shows normal interval growth. Which of the following is the most appropriate next step in management?

A hospital quality improvement committee is reviewing a recent medication administration event. A nurse working on a busy telemetry unit administered 10 mg of intravenous morphine instead of the ordered 5 mg. The patient experienced mild sedation but remained hemodynamically stable and required no reversal agents. Subsequent investigation reveals that 5 mg/mL and 10 mg/mL morphine vials, which have nearly identical packaging, were stocked in adjacent compartments within the unit's automated medication dispensing system. The nurse selected the incorrect vial during a period of high clinical volume. Which of the following is the most appropriate next step to prevent a recurrence of this event?

A 28-year-old primigravida at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Continuous fetal heart rate monitoring reveals recurrent late decelerations with absent variability. The physician informs the patient that the fetus is in distress and strongly recommends an emergency cesarean delivery to prevent severe fetal injury or death. The patient is fully alert, oriented, and demonstrates a clear understanding of the risks, including the high probability of fetal demise. However, she adamantly refuses the surgery, stating that she will only allow a natural vaginal birth. Which of the following is the most appropriate next step in management?

A 32-year-old woman, gravid 1, para 0, at 39 weeks gestation is admitted to the hospital in active labor. Her cervical dilation is 6 cm. Fetal heart rate monitoring reveals a baseline of 140/min with minimal variability and recurrent late decelerations. The physician informs the patient that the fetal heart rate tracing is nonreassuring and strongly recommends an emergency cesarean delivery to prevent fetal brain injury or demise. The patient is alert, fully oriented, and exhibits intact decision-making capacity. She states that she clearly understands the severe risks to the fetus if surgery is not performed. However, she refuses the cesarean delivery due to a deep-seated fear of operative procedures and insists on continuing with a vaginal delivery. Which of the following is the most appropriate next step in management?

An adolescent, age 17, who is 34 weeks pregnant, presents to the obstetric triage unit with a severe headache and blurred vision. Her blood pressure is 170/110 mm Hg, and laboratory evaluation is consistent with severe preeclampsia. The attending physician strongly advises immediate hospital admission, intravenous magnesium sulfate therapy, and expedited delivery. A psychiatric evaluation confirms that the patient possesses full decision-making capacity and comprehends the severe risks of declining care, including maternal seizures and fetal demise. However, the adolescent adamantly declines admission, stating that attending her senior prom tonight is more important to her. Her mother, who accompanied her, is terrified and demands that the medical team administer the necessary treatments to protect her daughter and the fetus, regardless of the adolescent's objections. According to standard legal and ethical guidelines, which of the following actions are appropriate in the management of this case? (Select all that apply)

Evaluate the following complex ethical scenarios involving pediatric and maternal-fetal patients. Match each clinical situation with the most appropriate ethical or legal management strategy.

A 58-year-old woman comes to the clinic reporting a 6-week history of a progressively enlarging mass on the right side of her face. She also reports soaking night sweats and a 4-kg (8.8-lb) unintentional weight loss over the past 2 months. She has a 12-year history of primary Sjögren syndrome, which is managed with artificial tears and pilocarpine. Physical examination reveals a 4-cm, firm, non-tender, immobile mass in the right parotid region. Right-sided cervical lymphadenopathy is also present. Her past parotid enlargements associated with her autoimmune disease were bilateral, soft, and fluctuated in size. Laboratory studies show an elevated lactate dehydrogenase (LDH) level. Which of the following is the most likely etiology of this patient's new symptoms?

A $31$-year-old woman comes to the clinic due to an $18$-month history of inability to conceive. She and her partner have been having regular, unprotected intercourse. Her menstrual periods, previously regular, now occur every $50$ to $60$ days. The patient also reports a $5\text{-kg}$ ($11\text{-lb}$) weight gain, sluggishness, and increased sensitivity to cold over the past year. Her BMI is $28\ \text{kg/m}^2$. Vital signs show a temperature of $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$) and a pulse of $56\text{/min}$. Physical examination reveals an enlarged, firm, and non-tender thyroid gland, as well as bilateral milky discharge from the nipples. A urine pregnancy test is negative.

Laboratory results:
Thyroid-stimulating hormone (TSH): $22.5\ \mu\text{U/mL}$ (Normal: $0.4$ – $4.0\ \mu\text{U/mL}$)
Free thyroxine (T4): $0.5\ \text{ng/dL}$ (Normal: $0.9$ – $1.7\ \text{ng/dL}$)
Prolactin: $68\ \text{ng/mL}$ (Normal: $4$ – $23\ \text{ng/mL}$)

Which of the following is the most likely pathophysiologic mechanism responsible for this patient's infertility?

Match each clinical vignette to the autoantibody profile most specific for the suspected underlying rheumatologic or autoimmune condition.

A $72$-year-old man is evaluated in a skilled nursing facility due to a $4$-day history of frequent, watery, foul-smelling stools and diffuse lower abdominal cramping. Two weeks ago, he completed a $7$-day course of oral amoxicillin-clavulanate for a chronic obstructive pulmonary disease exacerbation. His temperature is $37.8^{\circ}\text{C}$ ($100.0^{\circ}\text{F}$), blood pressure is $128/78\text{ mm Hg}$, and pulse is $92/\text{min}$. Physical examination reveals mild, diffuse abdominal tenderness without guarding or rebound. Laboratory testing shows a leukocyte count of $14,000/\text{mm}^3$ and a serum creatinine of $1.1\text{ mg/dL}$. A stool enzyme immunoassay is positive for both glutamate dehydrogenase antigen and *Clostridioides difficile* toxins A and B. Which of the following is the most appropriate targeted pharmacotherapy for this patient's current condition?

A 28-year-old man with a 5-year history of ulcerative colitis is admitted to the hospital with a severe disease flare, characterized by up to $12$ bloody bowel movements daily and severe abdominal cramping. He was started on high-dose intravenous methylprednisolone $3$ days ago. Today, he appears profoundly lethargic and confused. Vital signs show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $88/50\text{ mm Hg}$, and pulse of $132/\text{min}$. Physical examination reveals a markedly distended, tympanitic abdomen with diffuse rigidity, involuntary guarding, and absent bowel sounds. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$ and serum lactate of $5.1\text{ mmol/L}$. An upright chest radiograph reveals free air under the right hemidiaphragm. The patient's legally appointed healthcare proxy (his brother) is en route to the hospital and is currently unreachable by phone. His girlfriend, who is at the bedside, requests that the medical team wait for the brother before proceeding with any major interventions. What is the most appropriate next step in the management of this patient?