All practice questions

A $5$-year-old boy is brought to the clinic by his parents due to rapid growth, facial acne, and the development of pubic hair over the past $6$ months. The parents also report that he has recently developed adult-type body odor. His height is at the $99$ th percentile for his age, whereas it was at the $50$ th percentile one year ago. His weight is at the $90$ th percentile. Vital signs are within normal limits. Physical examination reveals coarse, dark pubic hair (Tanner stage III) and facial acne. Genitourinary examination shows a stretched penile length of $6$ cm and bilaterally enlarged, symmetric testes with a volume of $8$ mL each. Neurologic examination is unremarkable.

Laboratory studies show:
Testosterone: $180$ ng/dL (Normal prepubertal: $<30$ ng/dL)
Basal luteinizing hormone (LH): $0.1$ mIU/mL (Normal prepubertal: $<0.3$ mIU/mL)
Thyroid-stimulating hormone (TSH): $1.8$ $\mu$ U/mL

A radiograph of the left hand and wrist reveals a bone age of $8$ years.

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

A $6$-month-old boy is brought to the clinic by his parents due to abnormal movements. Over the past $2$ weeks, he has had multiple episodes daily where he suddenly bends his head and trunk forward while stiffening his arms. These episodes occur in clusters, most often just after waking up from a nap. The parents are also highly concerned about his development because he has not yet begun to crawl or pull himself to a stand, though he rolls over in both directions and babbles. Vital signs are within normal limits. Neurologic examination shows a slightly hypotonic infant. Skin examination reveals three $2\text{-cm}$, elliptical, hypopigmented macules on his trunk that are accentuated under a Wood lamp. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $2.5\ \mu\text{U/mL}$ and a free T4 of $1.2\ \text{ng/dL}$. An electroencephalogram demonstrates a high-voltage, chaotic, slow-wave background with multifocal spikes. Which of the following is the most appropriate next step in management?

Correlate each of the following clinical encounters or professional scenarios with the legally or ethically mandated next step regarding disclosure.

An internal medicine rapid response team is activated for a $68$-year-old hospitalized male who developed profound lower extremity weakness and lethargy. The patient was admitted two days ago for a diabetic foot infection and is receiving intravenous piperacillin-tazobactam. His home medications, including lisinopril and spironolactone for heart failure with reduced ejection fraction, were continued on admission. Over the past $12$ hours, his urine output has dropped significantly to $150$ mL. Vital signs demonstrate a heart rate of $42$/min and a blood pressure of $98/60$ mmHg. A point-of-care basic metabolic panel reveals a serum potassium of $7.8$ mEq/L and a serum creatinine of $3.2$ mg/dL (baseline $1.4$ mg/dL). A stat $12$-lead electrocardiogram demonstrates widened QRS complexes, absent P waves, and peaked T waves.

Arrange the following management steps in the most appropriate chronological sequence for this patient's acute presentation, from the most immediate intervention to subsequent actions.

An 18-month-old boy is brought to the pediatric pulmonology clinic due to persistent respiratory difficulties. Three months ago, he was hospitalized in the pediatric intensive care unit for a severe lower respiratory tract infection caused by *Adenovirus*, which required mechanical ventilation for seven days. Since discharge, he has exhibited continuous tachypnea, a daily wet cough, and audible wheezing. The patient has had no recent fever or rhinorrhea. Two separate five-day courses of oral prednisolone and regular administration of nebulized albuterol have provided no symptomatic relief. On physical examination, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate is $130/\text{min}$, respiratory rate is $52/\text{min}$, and oxygen saturation is $91\%$ on room air. Pulmonary auscultation reveals diffuse, bilateral expiratory wheezes and coarse crackles. A chest radiograph demonstrates bilateral hyperinflation without focal consolidation. Which of the following is the most appropriate next step in the evaluation or management of this patient?

A 16-year-old girl, who recently immigrated from a region with limited access to pediatric healthcare, is brought to the clinic for evaluation of primary amenorrhea and severe, progressive facial hair growth. Her mother notes that she has had a deep voice and experienced a rapid growth spurt during early childhood. Her blood pressure is 162/100 mm Hg, and her pulse is 78/min. Physical examination reveals severe nodulocystic acne, temporal hair thinning, and Tanner stage 5 pubic hair development, but Tanner stage 1 breast development. Pelvic examination demonstrates significant clitoromegaly and partial fusion of the labioscrotal folds. A transabdominal pelvic ultrasound confirms the presence of a uterus and bilateral ovaries. Laboratory testing shows a serum sodium of 146 mEq/L and a serum potassium of 2.8 mEq/L. Which of the following serum laboratory profiles (17-hydroxyprogesterone, 11-deoxycorticosterone, and plasma renin activity) is most likely present in this patient?

In early February, the parents of an 18-month-old girl bring her to the emergency department because she has been breathing rapidly and feeding poorly for the past 24 hours. The parents note that her symptoms began four days ago with a runny nose, mild nasal congestion, and a "tight" cough. She has a past medical history of atopic dermatitis managed with emollients. Her immunizations are up to date. Her temperature is 37.9°C (100.2°F), pulse is 158/min, respirations are 58/min, and oxygen saturation is 89% on room air. Physical examination reveals an irritable but consolable toddler with prominent nasal flaring and subcostal retractions. Lung auscultation demonstrates a prolonged expiratory phase, diffuse polyphonic wheezing, and bilateral coarse crackles. A chest radiograph displays bilateral hyperinflation, flattened hemidiaphragms, and a focal, wedge-shaped area of increased opacity in the right middle lobe. Which of the following is the most appropriate next step in management?

A 12-year-old boy is brought to the clinic for a 4-week history of right-sided knee pain and a progressive limp. The pain is characterized as a dull ache that is exacerbated by walking and participating in sports. He has no history of trauma, falls, or fever. His medical history is significant for growth hormone deficiency, for which he has been receiving somatropin injections for the past 6 months. His body mass index is at the 60th percentile for his age. His temperature is 37.1°C (98.8°F), blood pressure is 110/70 mm Hg, and pulse is 78/min. On physical examination, there is no swelling, erythema, or localized tenderness over the right knee, and ligamentous testing is stable. Range of motion of the right knee is full and painless. When the patient walks, he exhibits an antalgic gait with the right foot pointing outward. During examination of the hips, passive flexion of the right hip results in obligate external rotation of the thigh. Internal rotation of the right hip is limited compared to the left. Which of the following is the most appropriate next step in management?

A $72$-year-old woman is brought to the emergency department for sudden-onset severe shortness of breath, lightheadedness, and right-sided chest pain. She recently returned from a $12$-hour international flight two days ago. Her medical history includes moderate chronic obstructive pulmonary disease (COPD) and hypertension.

On arrival, she is somnolent but arousable. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $118/\text{min}$, and respirations are $28/\text{min}$. Oxygen saturation is $85\%$ on room air.

Physical examination reveals elevated jugular venous pressure. Lung auscultation is clear bilaterally.

Bedside transthoracic echocardiography demonstrates a severely enlarged right ventricle with hypokinesis of the free wall and normal apical contraction. The left ventricle is small and hyperdynamic.

An arterial blood gas on room air shows:
pH: $7.29$
$\text{PaCO}_2$: $26\text{ mm Hg}$
$\text{PaO}_2$: $54\text{ mm Hg}$
$\text{HCO}_3^-$: $12\text{ mEq/L}$

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

A 32-year-old woman is brought to the emergency department by her partner due to 5 days of severe, voluminous diarrhea and abdominal cramping. She has a history of ulcerative colitis and panic disorder. In the waiting room, she experienced a severe panic attack and was noted to have visibly rapid, deep breathing. Physical examination reveals dry mucous membranes, decreased skin turgor, a heart rate of $115/\text{min}$, a respiratory rate of $28/\text{min}$, and a blood pressure of $105/65\text{ mm Hg}$.

Laboratory results are as follows:

Arterial blood gas (room air):

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

Match each post-bariatric surgery clinical presentation with its most appropriate diagnostic or therapeutic next step.

A 58-year-old man collapses in the hospital lobby. A nearby physician confirms he is unresponsive, apneic, and lacks a palpable carotid pulse. A resuscitation team arrives immediately with a crash cart, and the initial cardiac monitor displays coarse ventricular fibrillation. Arrange the following interventions in the correct chronological sequence according to standard Advanced Cardiac Life Support (ACLS) guidelines for adult cardiac arrest.

A $31$-year-old woman, G $1$ P $0$ at $34$ weeks gestation, is brought to the emergency department after being involved in a high-speed motor vehicle collision. She complains of anterior chest pain and severe shortness of breath. Her blood pressure is $78/48$ mm Hg, heart rate is $135$ bpm, and respiratory rate is $26$/min. Pulse oximetry shows $93\%$ on room air. Physical examination reveals distended jugular veins and distant, muffled heart sounds. Breath sounds are equal bilaterally, but faint scattered wheezes are auscultated. The trachea is midline. Bedside focused assessment with sonography for trauma (FAST) demonstrates a large anechoic space surrounding the heart with right ventricular free wall inversion during diastole. There is no evidence of intraperitoneal fluid. Continuous fetal heart rate monitoring shows a baseline of $140$ bpm with moderate variability and no decelerations. Which of the following is the most appropriate next step in management for this patient?

An established clinic patient, who is 68 years old, presents for evaluation of bilateral leg swelling that has gradually worsened over the past 3 months. He additionally notes new-onset abdominal fullness and becoming breathless after walking short distances. The patient is oxygen-dependent due to a long-standing history of severe chronic obstructive pulmonary disease (COPD) and has previously smoked heavily for four decades. His temperature is 37.0°C (98.6°F), blood pressure is 135/85 mm Hg, and pulse is 88/min. Physical examination reveals markedly distended jugular veins, a palpable parasternal heave, and 3+ pitting edema of the lower extremities bilaterally. Cardiac auscultation reveals a holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. Breath sounds are decreased bilaterally with a prolonged expiratory phase, but no crackles are heard. Which of the following is the most likely primary mechanism for this patient's current presentation?

Match each clinical presentation and characteristic physical examination finding with the most likely underlying valvular pathology.

A 72-year-old woman is brought to the emergency department at 3:00 AM due to the sudden onset of severe shortness of breath and wheezing that awoke her from sleep. She has a history of essential hypertension, type 2 diabetes mellitus, and a 35-pack-year smoking history. Current medications include amlodipine and metformin. Her blood pressure is 170/95 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oximetry shows 90% on room air. Physical examination reveals diffuse bilateral expiratory wheezing and a prolonged expiratory phase. Jugular venous pulsation is estimated at 9 cm H₂O. Cardiac auscultation reveals a regular rate and rhythm with a prominent S4 gallop; no murmurs are appreciated. Trace bilateral lower extremity edema is present. An electrocardiogram shows normal sinus rhythm with voltage criteria for left ventricular hypertrophy. A chest radiograph reveals a slightly enlarged cardiac silhouette but no focal consolidation or pleural effusion. The patient is administered continuous nebulized albuterol and intravenous methylprednisolone for a presumed chronic obstructive pulmonary disease exacerbation. One hour later, her dyspnea acutely worsens. Repeat vital signs show a blood pressure of 120/70 mm Hg and a pulse of 128/min. Repeat lung auscultation now reveals prominent bibasilar crackles extending to the mid-lung fields. Which of the following pathophysiologic mechanisms best explains this patient's acute clinical deterioration?

Match each patient's clinical presentation and laboratory profile to the most likely underlying pathophysiologic mechanism.

A 58-year-old individual undergoing maintenance hemodialysis is admitted to the hospital due to progressive shortness of breath, orthopnea, and generalized fatigue over the past month. The patient has a history of type 2 diabetes mellitus and underwent creation of a left brachiocephalic arteriovenous fistula six months ago. Current medications include sevelamer, amlodipine, and erythropoietin. Vital signs reveal a blood pressure of $165/55$ mmHg, a pulse of $110$/min with bounding peripheral pulses, and a respiratory rate of $22$/min. Oxygen saturation is $93\%$ on ambient air. Physical examination demonstrates distended jugular veins up to $9$ cm $H_2O$. Auscultation of the lungs reveals bilateral basilar crackles and scattered expiratory wheezes. Cardiac examination shows a hyperdynamic precordium, a soft systolic ejection murmur at the left upper sternal border, and an audible S3 gallop. The left arm exhibits a very prominent thrill and a continuous bruit over the access site. Echocardiography demonstrates a left ventricular ejection fraction of $68\%$, biatrial enlargement, and a dilated left ventricle. Which of the following best describes the primary underlying hemodynamic derangement responsible for this patient's current symptoms?

A 68-year-old man presents to the urgent care clinic with a 2-day history of progressively worsening shortness of breath and cough. He states that he is having to work much harder to breathe than usual. His past medical history is significant for a myocardial infarction 3 years ago and chronic obstructive pulmonary disease (COPD) managed with an inhaled long-acting bronchodilator. He has a 40-pack-year smoking history. Temperature is 37.0°C (98.6°F), blood pressure is 152/90 mmHg, pulse is 108/min, and respiratory rate is 26/min. Oxygen saturation is 89% on room air. Lung auscultation reveals diffuse expiratory wheezes and scattered basilar crackles. Cardiac examination is difficult to hear clearly due to loud breath sounds, and the neck veins are not easily visible due to his body habitus. Which of the following is the most appropriate next diagnostic test to determine whether his symptoms are primarily due to acute decompensated heart failure rather than a COPD exacerbation?

A 24-year-old woman with type 1 diabetes mellitus presents to the emergency department with abdominal pain, nausea, vomiting, and deep, rapid breathing. Vital signs show a heart rate of $118\text{ /min}$ and blood pressure of $90/60\text{ mmHg}$. Laboratory studies show a blood glucose of $480 \text{ mg/dL}$, an arterial pH of 7.15, positive serum ketones, and a serum potassium of $4.8 \text{ mEq/L}$. Arrange the following management steps in the most appropriate chronological sequence for this patient.