All practice questions

Match each clinical scenario describing a medication-induced renal, electrolyte, or acid-base abnormality to the corresponding causative pharmacological agent.

A 72-year-old woman presents to the emergency department with a 2-day history of right-sided temporal headache, jaw pain with chewing, and scalp tenderness. This morning, she experienced a 10-minute episode of painless visual loss in her right eye that has since resolved. Her temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, and pulse is $84/\text{min}$. Physical examination reveals a prominent, tender right temporal artery with diminished pulsation. Laboratory studies show an erythrocyte sedimentation rate (ESR) of $105\text{ mm/h}$. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 19-year-old male college student is brought to the emergency department by paramedics after experiencing a generalized tonic-clonic seizure that lasted 2 minutes. His roommate reports that the patient had complained of a severe headache, nausea, and high fever for the past 12 hours. His temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), blood pressure is $98/60$ mmHg, and heart rate is $124$/min. On physical examination, the patient is lethargic, postictal, and mildly confused. Pronounced nuchal rigidity is present. A non-blanching petechial rash is observed on his bilateral lower extremities.

Arrange the following next steps in management in the most appropriate chronological order for this patient.

An otherwise healthy 36-month-old girl is evaluated via a telehealth consultation for a routine health maintenance visit. Her parents express anxiety regarding her developmental progress compared to other children in her playgroup. Specifically, they note that she cannot hop on one foot or draw a cross on paper. During the video observation, the physician notes the child pedaling a small tricycle across the room and walking up a set of stairs using alternating feet. When given crayons, she successfully copies a circle but simply scribbles when attempting to copy a square. She answers the physician's questions using three-word sentences, and the physician easily understands approximately 75% of what she says. She correctly states her name and age when asked. Based on this presentation, which of the following is the most appropriate next step in management?

A 12-month-old boy is brought to the pediatrician for a routine well-child visit. His medical history is significant for perinatal HIV infection. He is currently prescribed antiretroviral therapy, but his mother admits to frequently missing doses over the past few months. Recent laboratory studies show a CD4 T-lymphocyte count of 450 cells/mm³ and a CD4 percentage of 12%. The parents express concern about his physical development, noting that he is not yet able to run or kick a ball. On examination, the boy is alert and interactive. He can stand independently for a few seconds and uses a fine pincer grasp to pick up a raisin. He says "mama" and "dada" specifically and waves "bye-bye" to the clinician. He has received all previously recommended immunizations. Which of the following is the most appropriate next step in the management of this patient?

An internal medicine team is evaluating a $67$-year-old male who presented to the emergency department with a $5$-day history of progressively worsening shortness of breath, orthopnea, and lower extremity swelling. His medical history includes seropositive rheumatoid arthritis, for which infliximab was added to his methotrexate regimen $4$ months ago due to refractory joint pain. He also has a $35$-pack-year smoking history. On physical examination, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $112/74\text{ mm Hg}$, heart rate is $110\text{ /min}$, and respiratory rate is $24\text{ /min}$. Pulse oximetry shows $91\%$ on ambient air. Jugular venous distention is prominent at $45$ degrees. Chest auscultation reveals bilateral basilar crackles and a prominent third heart sound (S3). There is $2+$ bilateral pitting edema extending to the knees. Joint examination shows no active synovitis, warmth, or effusions. Which of the following is the most appropriate next step in the pharmacologic management of this patient's current condition?

A 32-year-old man is admitted to the hospital with a 1-week history of fever, chills, and profound fatigue. He has a history of intravenous drug use and was treated for a skin abscess two months ago. His temperature is 38.8°C (101.8°F), blood pressure is 110/70 mm Hg, and pulse is 108/min. Physical examination reveals a new grade 3/6 holosystolic murmur best heard at the cardiac apex. Transesophageal echocardiography demonstrates a 1.2-cm mobile vegetation on the mitral valve. Three sets of blood cultures obtained on admission grow *Enterococcus faecalis* that is susceptible to ampicillin, vancomycin, gentamicin, and linezolid. The patient is initiated on continuous intravenous ampicillin and every-8-hour intravenous gentamicin. Over the next 48 hours, his clinical symptoms improve and his temperature decreases to 37.9°C (100.2°F). However, laboratory studies show his serum creatinine has increased from 0.8 mg/dL on admission to 2.5 mg/dL, and his urine output has been 350 mL over the past 24 hours. Which of the following is the most appropriate modification to this patient's antimicrobial regimen?

During routine well-child care, clinicians follow standardized periodicity schedules to ensure appropriate preventive screening for asymptomatic children and adolescents. Arrange the following universal preventive screening assessments in chronological order, starting with the earliest recommended age of initial administration to the latest.

A 22-year-old man presents to the emergency department with a 2-day history of worsening nausea, diffuse abdominal pain, and profound fatigue. He has been excessively thirsty and urinating frequently. He has no significant past medical history. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $98/60\text{ mmHg}$, heart rate is $118/\text{min}$, and respiratory rate is $24/\text{min}$ with deep, rapid breaths. Mucous membranes are dry. The abdomen is diffusely tender but soft without rebound. Point-of-care testing reveals a capillary blood glucose of $480\text{ mg/dL}$ and large blood ketones. An arterial blood gas shows a pH of $7.18$. The patient is diagnosed with an acute endocrine emergency.

Arrange the following management steps in the most appropriate algorithmic sequence for the acute stabilization and definitive therapy of this patient.

During morning rounds, a $58$-year-old male inpatient is evaluated on postoperative day $7$ following an open partial gastrectomy for gastric adenocarcinoma. The patient reports new-onset severe right calf pain and swelling that began earlier this morning, along with mild shortness of breath. His medications include pantoprazole and subcutaneous unfractionated heparin, which was started postoperatively for venous thromboembolism prophylaxis. Temperature is $37.8^\circ \text{C}$ ($100.0^\circ \text{F}$), blood pressure is $135/85 \text{ mmHg}$, pulse is $105/\text{min}$, and respirations are $18/\text{min}$. Pulse oximetry shows $96\%$ on room air. Physical examination reveals a swollen, erythematous, and tender right calf. Lungs are clear to auscultation bilaterally.

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

A male patient, aged $48$, presents to an ambulatory care facility reporting a $6$-week history of a persistent cough and episodes of blood-tinged sputum. Over this same period, he has experienced recurrent nosebleeds, intermittent low-grade fevers, and profound fatigue. His medical history includes major depressive disorder, for which he has been taking citalopram for the last $3$ years. He does not smoke or use illicit drugs.

Vital signs show a temperature of $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), blood pressure of $152/96\text{ mm Hg}$, heart rate of $88/\text{min}$, and respiratory rate of $16/\text{min}$.

Examination of the nasal cavity reveals mucosal ulcerations and adherent crusts. Auscultation of the lungs demonstrates scattered crackles in the right middle lung field.

Laboratory studies reveal:
Hemoglobin: $10.2\text{ g/dL}$
Leukocyte count: $11,500/\text{mm}^3$
Blood urea nitrogen: $34\text{ mg/dL}$
Serum creatinine: $2.2\text{ mg/dL}$ (was $0.8\text{ mg/dL}$ during a routine checkup $8$ months ago)
Urinalysis: $2+$ protein, large blood, $>50\text{ red blood cells/hpf}$, and several red blood cell casts.

A radiograph of the chest demonstrates a $3.5\text{-cm}$ cavitary lesion in the right middle lobe with thick walls.

Based on the most likely diagnosis, which of the following is the most appropriate next step in evaluation or management?

A 32-year-old woman with a history of systemic lupus erythematosus and recurrent kidney stones is evaluated in the clinic for progressive, generalized muscle weakness over the past two weeks. She reports difficulty climbing stairs and rising from a seated position. She denies diarrhea, vomiting, fever, or recent illnesses. Her vital signs are within normal limits. Physical examination reveals symmetric proximal muscle weakness in the bilateral lower extremities with diminished deep tendon reflexes.

Laboratory evaluation shows the following:

Serum chemistry:
Sodium: 140 mEq/L
Potassium: 2.6 mEq/L
Chloride: 114 mEq/L
Bicarbonate: 14 mEq/L
Blood urea nitrogen: 16 mg/dL
Creatinine: 0.9 mg/dL

Arterial blood gas (room air):
pH: 7.26
pCO2: 29 mm Hg
pO2: 96 mm Hg

Urinalysis reveals a pH of 6.8 with no protein or blood.

Based on the provided laboratory data, which of the following statements is most accurate regarding this patient's current acid-base physiological state?

Match each clinical vignette describing a systemic fungal infection with the most appropriate first-line pharmacotherapy.

Emergency medical services transport a $65$-year-old man from a long-term care facility to the hospital due to acute-onset confusion, fever, and severe abdominal pain. His past medical history is significant for alcohol-associated cirrhosis with refractory ascites, which is managed with high-dose furosemide and spironolactone. Upon arrival, his temperature is $39.2^\circ$ C ($102.6^\circ$ F), blood pressure is $80/50$ mm Hg, heart rate is $122$/min, and respiratory rate is $28$/min. Abdominal examination reveals severe distension, diffuse tenderness, and involuntary guarding. Laboratory results are as follows:

Based on the clinical presentation and laboratory results, which of the following sets of acid-base disorders is present in this patient?

Match each classic pediatric respiratory clinical presentation with its most likely causative pathogen.

During routine evaluations in the newborn nursery and outpatient pediatric clinic, various abdominal and genitourinary structural anomalies are identified. Accurate diagnosis relies on distinct physical characteristics, which directly dictate the need for further workup and specific prognostic counseling. Match each neonatal clinical presentation to its corresponding underlying pathophysiologic mechanism and classic clinical associations.

Match each characteristic physical examination or radiographic hand finding to the most likely underlying rheumatologic or musculoskeletal condition.

A 54-year-old man with a history of severe alcohol use disorder is admitted to the intensive care unit with acute necrotizing pancreatitis. Over the past 72 hours, he has experienced intractable vomiting and an inability to tolerate any oral intake. On physical examination, the patient is lethargic. Mucous membranes are extremely dry, and skin turgor is poor. Vital signs show a blood pressure of 88/50 mmHg, a pulse of 118/min, and a respiratory rate of 22/min.

Laboratory studies reveal the following:

The physician evaluates the patient's acid-base status. Assuming a baseline normal anion gap of 12 mEq/L and a normal serum bicarbonate of 24 mEq/L, what is the patient's calculated delta ratio ($\Delta\text{AG}/\Delta\text{HCO}_3^-$) after appropriately correcting the anion gap for his hypoalbuminemia?

A $45$-year-old woman is brought to the emergency department by her husband due to a severe, throbbing headache, blurred vision, and worsening shortness of breath over the past $48$ hours. She was diagnosed with diffuse cutaneous systemic sclerosis $3$ years ago. Her home medications include mycophenolate mofetil. She recently visited an urgent care clinic for dysuria, and a urine culture sent at that time grew $>100,000$ CFU/mL of *Escherichia coli* susceptible to amoxicillin, nitrofurantoin, and ceftriaxone. She has not yet started antibiotic therapy.

Today, her temperature is $37.1^\circ C$ ($98.8^\circ F$), blood pressure is $225/125$ mmHg, pulse is $110$/min, and respirations are $26$/min. Oxygen saturation is $93\%$ on room air. Physical examination reveals taut, thickened skin over the face, chest, and upper extremities. Funduscopic examination demonstrates bilateral papilledema and flame-shaped hemorrhages. Lung auscultation reveals fine bibasilar crackles.

Laboratory results are as follows:

Arterial blood gas on room air:
pH: $7.32$
pCO₂: $30$ mmHg
pO₂: $72$ mmHg
HCO₃⁻: $15$ mEq/L

Peripheral blood smear shows numerous schistocytes.

Which of the following is the most appropriate initial step in the management of this patient's condition?

During routine rounding in the neonatal intensive care unit, a physician evaluates a male newborn delivered $60$ minutes ago via elective cesarean section at $38$ weeks of gestation. The mother's pregnancy was complicated by diet-controlled gestational diabetes. The infant, weighing $3,400\text{ g}$, had Apgar scores of $7$ and $9$ at $1$ and $5$ minutes, respectively. He was admitted to the unit for close monitoring due to increased work of breathing. Current vital signs show a temperature of $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), pulse of $158/\text{min}$, and respirations of $78/\text{min}$. He is maintaining an oxygen saturation of $94\%$ on continuous positive airway pressure (CPAP). Physical examination reveals mild intercostal retractions. Detailed skin inspection shows scattered, non-erythematous, superficial vesicles and small pustules over the chin, neck, and lower back. Several of these lesions have ruptured, leaving a collarette of scale surrounding a flat, hyperpigmented macule. Laboratory evaluation reveals a leukocyte count of $18,000/\text{mm}^3$ with a normal differential. A Wright-stained smear of fluid from an intact pustule demonstrates numerous neutrophils and no bacteria. Chest radiography displays increased lung volumes, prominent perihilar vascular markings, and fluid in the minor fissure. Which of the following is the most appropriate next step in management?