All practice questions

A 27-year-old woman presents to the reproductive endocrinology clinic with her partner because they have been unable to conceive for the past 15 months despite regular unprotected intercourse. She reports that her menstrual periods have been unpredictable since menarche, typically occurring only 3 or 4 times a year. Her medical history is unremarkable, and she takes no medications. Vital signs include a blood pressure of 122/78 mmHg and a body mass index (BMI) of 33 kg/m $^2$. Physical examination reveals dark, thickened, velvety plaques on the posterior neck and axillae, as well as coarse, dark hair on her upper lip, chin, and chest. Laboratory evaluation shows an elevated serum free testosterone level, a normal thyroid-stimulating hormone (TSH) level, a normal prolactin level, and a normal early morning 17-hydroxyprogesterone level. A pelvic ultrasound demonstrates bilaterally enlarged ovaries with multiple small, peripherally arranged cysts. Which of the following pathophysiologic mechanisms is the primary driver of this patient's anovulatory infertility?

A 38-year-old woman is evaluated in the outpatient clinic for a 6-month history of profound fatigue, progressive generalized weakness, dry skin, and constipation. She also reports frequent lightheadedness, particularly when standing up quickly. The patient has not menstruated for the past 5 months, although she previously had regular cycles. Her last pregnancy was 4 years ago and was uncomplicated. She takes no medications and does not use illicit drugs. Her body mass index is $22 \text{ kg/m}^2$. Vital signs show a blood pressure of $92/58 \text{ mm Hg}$ while supine that drops to $80/50 \text{ mm Hg}$ upon standing. Her heart rate is $58/\text{min}$. Physical examination reveals pale, dry skin and sparse axillary and pubic hair. The relaxation phase of the ankle reflexes is significantly delayed.

Laboratory studies show:
Hemoglobin: $11.2 \text{ g/dL}$
Sodium: $132 \text{ mEq/L}$
Potassium: $4.1 \text{ mEq/L}$
Thyroid-stimulating hormone (TSH): $0.15 \text{ \mu U/mL}$ (normal: $0.4 - 4.0 \text{ \mu U/mL}$)
Free thyroxine (T4): $0.3 \text{ ng/dL}$ (normal: $0.9 - 2.4 \text{ ng/dL}$)

Which of the following additional laboratory findings is most likely present in this patient?

Match each infectious exposure scenario with the most appropriate guideline-directed post-exposure prophylaxis or preemptive pharmacotherapy.

While recovering in the surgical ward, a 65-year-old man develops acute-onset, severe abdominal pain. He is currently 8 days status post an open ventral hernia repair with mesh placement. His initial recovery was uncomplicated; he began passing flatus on the fourth day after surgery and was tolerating a regular diet. Over the past 24 hours, he has experienced progressive abdominal distension, nausea, and two episodes of bilious vomiting. He has not passed flatus since the pain began. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $88/50 \text{ mmHg}$, pulse is $122/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals a markedly distended abdomen. There is diffuse tenderness with involuntary guarding and rebound tenderness, most prominent in the periumbilical region. Bowel sounds are absent. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$, a serum bicarbonate level of $14 \text{ mEq/L}$, and a lactate level of $4.2 \text{ mmol/L}$. An upright abdominal radiograph demonstrates multiple dilated loops of small intestine with prominent air-fluid levels and a paucity of colonic gas. Which of the following is the most appropriate next step in management?

A 38-year-old woman is evaluated in the outpatient clinic for progressive weight gain, proximal muscle weakness, and new-onset facial hair growth over the past 8 months. She takes no prescription or over-the-counter medications. Her temperature is 37.0°C (98.6°F), blood pressure is 158/98 mm Hg, pulse is 82/min, and BMI is 34 kg/m². Physical examination reveals facial plethora, a prominent dorsocervical fat pad, and wide, violaceous striae on the lower abdomen. Basic metabolic panel shows a serum potassium of 3.2 mEq/L and a fasting blood glucose of 145 mg/dL. The physician strongly suspects endogenous Cushing syndrome. Arrange the following diagnostic steps in the correct chronological sequence required to accurately diagnose and localize the etiology of this patient's condition.

A $54$-year-old woman with a history of type $2$ diabetes mellitus is evaluated in the hospital on day $3$ of admission for a liver abscess. She originally presented to the emergency department with a $4$-day history of right upper quadrant abdominal pain, high fever, and chills. At that time, an abdominal ultrasound revealed a $6\text{ cm}$ fluid collection in the right hepatic lobe. She underwent successful image-guided percutaneous drain placement and was empirically started on intravenous vancomycin, piperacillin-tazobactam, and metronidazole. Today, the patient reports significant improvement in her abdominal pain. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $124/78\text{ mm Hg}$, and pulse is $76/\text{min}$. The percutaneous drain has minimal purulent output. Both blood cultures and the initial abscess aspirate cultures (aerobic and anaerobic) are now growing pure *Klebsiella pneumoniae*. Susceptibility testing demonstrates the isolate is sensitive to ceftriaxone, cefepime, ciprofloxacin, and piperacillin-tazobactam, and is resistant to ampicillin. Which of the following is the most appropriate next step in pharmacotherapy?

A 58-year-old man with a history of alcohol-associated cirrhosis and refractory ascites is evaluated on hospital day 2. He initially presented with progressive confusion, fever, and diffuse abdominal discomfort. Upon admission, his temperature was $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure was $102/65\text{ mmHg}$, and heart rate was $105/\text{min}$. Physical examination demonstrated a tense, distended abdomen with shifting dullness and diffuse tenderness, but no guarding or rigidity.

Initial laboratory results from admission:

Diagnostic paracentesis performed in the emergency department yielded cloudy fluid with a leukocyte count of $850/\text{mm}^3$ ($85\%$ neutrophils). Total protein in the ascitic fluid was $0.8\text{ g/dL}$. Ascitic fluid cultures were sent, and the patient was empirically started on intravenous ceftriaxone.

Today, his temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $98/62\text{ mmHg}$, and pulse is $92/\text{min}$. He appears less confused. Urine output over the last 24 hours has been $600\text{ mL}$.

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

Match each clinical presentation of lower extremity pain with its most likely orthopedic diagnosis.

A 34-year-old female presents to the triage desk with a 6-hour history of sudden-onset, severe, and unrelenting periumbilical pain. She reports multiple episodes of bilious vomiting and an inability to keep any oral intake down since the pain began. Her surgical history is notable for a laparoscopic Roux-en-Y gastric bypass performed two years ago for severe obesity, resulting in a 45-kg (99-lb) weight loss. Her temperature is 38.6°C (101.5°F), blood pressure is 92/58 mmHg, pulse is 128/min, and respirations are 24/min. Physical examination reveals a markedly distended abdomen. There is diffuse tenderness to palpation, most prominent in the periumbilical region, with severe involuntary guarding and rebound tenderness. Bowel sounds are absent. Laboratory studies show a leukocyte count of 18,000/mm³ and a serum lactate level of 5.1 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old pregnant patient at 35 weeks gestation is brought to the emergency department with severe, painless vaginal bleeding. Ultrasound confirms complete placenta previa. Her blood pressure is 105/65 mm Hg, and pulse is 112/min. Laboratory studies show a hemoglobin level of 6.2 g/dL. The physician explains that without an immediate blood transfusion, both she and her fetus are at high risk for severe morbidity and mortality. The patient is fully alert, oriented, and demonstrates clear decision-making capacity. She states that her religious beliefs prohibit the acceptance of blood products and adamantly refuses the transfusion, though she consents to receiving intravenous crystalloid fluids. Which of the following is the most appropriate next step in management?

A 28-year-old woman presents to the clinic for evaluation of a painless ulcer on her vulva. Dark-field microscopy of a scraping from the ulcer confirms the presence of *Treponema pallidum*. The physician explains the diagnosis of primary syphilis and the need for intramuscular penicillin treatment. The patient becomes extremely anxious and begs the physician not to tell anyone, including the government or her husband. She tearfully reveals that her husband is highly controlling and frequently physically assaults her. She states, "If he finds out I have this, or if the police get involved, he will kill me." She has no children and there are no other dependents in the home. Which of the following is the most appropriate next step in management?

Match each clinical scenario describing a patient safety vulnerability or quality improvement intervention to the most appropriate human factors engineering concept.

An established 25-year-old male patient visits the outpatient clinic complaining of painful urination and urethral discharge. Laboratory testing confirms an active *Neisseria gonorrhoeae* infection. During the consultation, the patient becomes visibly enraged while discussing his recent job termination. He tells the physician, 'I purchased a firearm yesterday, and I am going to shoot my former manager when he walks out of the building tomorrow evening.' The patient then insists that the physician must keep everything discussed during the visit completely confidential. Which of the following actions are legally and ethically appropriate for the physician to take? (Select all that apply)

A hospital's quality improvement committee is reviewing a near-miss medication event on the medical-surgical unit. A registered nurse was preparing to administer intravenous vancomycin to a patient with sepsis. The barcode medication administration (BCMA) scanner on the unit's mobile computer cart had a drained battery because the charging port had been broken for several days. To ensure the patient received the time-sensitive antibiotic promptly, the nurse manually typed the patient's medical record number into the electronic health record and prepared to administer the drug without scanning the patient's wristband. During this manual entry, the nurse accidentally typed an adjacent patient's number. Fortunately, the adjacent patient's profile had an allergy alert for vancomycin, which triggered a hard stop in the system and led to the discovery of the error. The committee determines that nursing staff frequently use manual entry when scanners fail, considering it a necessary adaptation to maintain workflow and ensure timely medication delivery. Under the principles of a 'just culture,' which of the following is the most appropriate response by the committee regarding the nurse's actions?

A 68-year-old man is admitted to the hospital with a 3-week history of low-grade fever, fatigue, and progressive dyspnea on exertion. His medical history is significant for hypertension, type 2 diabetes mellitus, and stage 4 chronic kidney disease with a baseline serum creatinine of 2.8 mg/dL. His temperature is 38.2°C (100.8°F), blood pressure is 132/78 mmHg, and heart rate is 96/min. Physical examination reveals a new grade 3/6 holosystolic murmur heard best at the cardiac apex and radiating to the axilla. Small, dark red linear streaks are noted under the nail beds of both hands. A transesophageal echocardiogram demonstrates a 1.2-cm mobile vegetation on the posterior leaflet of the mitral valve with moderate mitral regurgitation. Three sets of blood cultures drawn 12 hours apart all grow *Enterococcus faecalis*. Antimicrobial susceptibility testing shows the isolate is susceptible to ampicillin, vancomycin, daptomycin, linezolid, and high-level gentamicin. Which of the following is the most appropriate definitive intravenous pharmacotherapy for this patient?

A 3-year-old girl is brought to the pediatrician by her parents for a routine well-child visit. The parents express concern that she might be experiencing developmental delays compared to her older brother at this age. They report that she cannot yet catch a bounced ball, hop on one foot, or draw a person. Furthermore, while she frequently speaks in three-word sentences, strangers can only understand her about 75% of the time, and she is unable to tell a cohesive story. Currently, the patient can safely ride a tricycle, alternate her feet when walking up a flight of stairs, copy a circle, and feed herself with a fork. She knows her age and gender and frequently engages in imaginative play. Vital signs are within normal limits. Physical examination reveals normal muscle tone, intact reflexes, and no dysmorphic features. Which of the following is the most appropriate next step in management?

A 28-year-old man presents to the emergency department with a bleeding wound on his right thigh. He reports that he was cleaning a recently purchased handgun when it accidentally discharged. The patient is hemodynamically stable. Examination reveals superficial entrance and exit wounds with no signs of major vascular or nerve injury. The wound is cleaned, and a tetanus toxoid vaccine is administered. During the encounter, the patient becomes visibly distressed and asks the physician not to document the cause of the injury or notify authorities. He explains that he is currently on parole for a prior felony conviction and fears that any police involvement will result in immediate incarceration. He is alert, oriented, and demonstrates clear decision-making capacity. Which of the following is the most appropriate next step regarding the patient's request?

A 36-month-old boy is brought to the clinic for a routine well-child evaluation. His parents express concern regarding his development, specifically noting that he frequently talks to an "invisible dinosaur" in his bedroom. They also report that he refuses to share toys with his peers at daycare, often snatching items away from other children during playtime. Furthermore, the parents mention that while they understand most of his speech, his daycare teachers and extended family members can only understand about 75% of what he says. The patient has no significant past medical history. On physical examination, the child is active and cooperative. He speaks in three-word sentences, successfully pedals a tricycle down the clinic hallway, copies a circle drawn by the physician, and builds a tower of 9 blocks. Which of the following is the most appropriate next step in management?

A 42-year-old woman with a 3-year history of limited cutaneous systemic sclerosis is evaluated in the clinic for progressively worsening episodic finger pain. She describes her fingers turning sharply demarcated white, then blue, and finally red upon exposure to cold temperatures. Recent episodes have become more frequent, lasting up to 30 minutes, and are starting to interfere with her work as a graphic designer. Arrange the following management steps for this patient's vasomotor symptoms in the standard sequential order of escalation, starting with the initial fundamental intervention and ending with advanced salvage therapy for refractory disease.

A 28-year-old man is brought to the emergency department with a 3-day history of high fevers, severe fatigue, and a new rash. He has a history of intravenous drug use. His temperature is 39.5°C (103.1°F), blood pressure is 108/60 mm Hg, pulse is 115/min, and respiratory rate is 18/min. Physical examination reveals a loud holosystolic murmur at the left lower sternal border that becomes louder with inspiration. Small, tender, erythematous nodules are present on the palmar surface of his fingertips. The patient appears acutely ill and toxic. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient.