All practice questions

An asymptomatic $65$-year-old woman visits her primary care physician for an annual checkup. She mentions feeling slightly more fatigued recently, though she attributes this to a busy daily routine. Her medical history includes well-controlled essential hypertension. Her temperature is $37.0^\circ$ C, blood pressure is $125/80$ mm Hg, and pulse is $72$/min. Physical examination reveals a normal-sized thyroid gland with no palpable nodules. A screening laboratory evaluation demonstrates the following results:

Thyroid-stimulating hormone (TSH): $7.8$ mU/L (normal: $0.4$-$4.2$ mU/L)
Free thyroxine (T4): $1.3$ ng/dL (normal: $0.8$-$2.7$ ng/dL)

Which of the following is the most likely diagnosis?

A $72$-year-old man is brought to the emergency department from a long-term care facility due to altered mental status. Facility staff report that the patient has experienced intractable vomiting and an inability to tolerate oral intake for the past $48$ hours. His past medical history includes hypertension, benign prostatic hyperplasia, and mild cognitive impairment. Upon arrival, his temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $88/54\text{ mm Hg}$, pulse is $118\text{/min}$, and respirations are $28\text{/min}$. Physical examination reveals dry mucous membranes, delayed capillary refill, and diffuse abdominal rigidity with severe rebound tenderness.

Based on the laboratory data provided, which of the following combinations of primary pathophysiologic processes best explains this patient's complete acid-base status?

A 36-hour-old term male neonate is evaluated in the neonatal intensive care unit for progressive abdominal distension and two episodes of bilious emesis. He was born at 39 weeks gestation via uncomplicated vaginal delivery. Vital signs are within normal limits for age. The infant has not yet passed meconium. Physical examination reveals a markedly distended, firm abdomen without overlying erythema. Bowel sounds are hypoactive. An imperforate anus is excluded by physical examination. The clinical team proceeds with evaluating and managing the patient for the most likely underlying condition. Assume that initial non-operative therapeutic interventions prove unsuccessful in completely relieving the obstruction, necessitating surgical escalation.

Arrange the following clinical steps in the most appropriate chronological sequence for the management and subsequent care of this patient.

Match each patient's clinical presentation with the most likely peripheral blood smear finding.

During a routine health maintenance visit, a $48$-year-old male construction worker describes a gradual decline in his energy levels and libido over the past $14$ months. He has also developed a pervasive feeling of being cold, even during summer months, alongside chronic, dull pain in the joints of his hands. He has no significant past medical history and takes no medications.

Vital signs include a blood pressure of $112/74$ mmHg and a heart rate of $58$/min. Physical examination reveals a slate-gray to bronze discoloration of the skin, which is most prominent in sun-exposed areas and old scars. Palpation of the abdomen reveals a firm, non-tender liver edge $3$ cm below the right costal margin. Testicular volume is reduced bilaterally. The relaxation phase of the deep tendon reflexes is noticeably delayed.

Laboratory evaluation demonstrates:

Based on the patient's presentation and laboratory findings, which of the following is the most appropriate next step in diagnostic evaluation?

A 32-year-old man comes to the clinic due to 5 days of severe, watery diarrhea. He recently returned from a trip to Southeast Asia. The patient reports having 8 to 10 loose bowel movements daily. He has been drinking plain water but has not consumed any food or electrolyte solutions. His temperature is 37.1°C (98.8°F), blood pressure is 108/64 mm Hg, and pulse is 104/min. Physical examination shows dry mucous membranes and decreased skin turgor. Laboratory studies show the following:

Based on these findings, which of the following acid-base disturbances is most likely present in this patient?

A 28-year-old woman presents to the emergency department with a 2-day history of sharp right-sided chest pain that worsens with deep inspiration. She also reports shortness of breath and generalized fatigue. She was diagnosed with systemic lupus erythematosus (SLE) three years ago and is currently prescribed hydroxychloroquine, though she admits to missing several doses recently. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $122/78\text{ mm Hg}$, pulse is $102/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals a pleural friction rub over the right lower lung field. Her wrists and metacarpophalangeal joints are tender and swollen bilaterally.

Laboratory studies are as follows:

Arterial blood gas analysis on room air:

Chest radiography shows a small right pleural effusion with no pulmonary infiltrates. Electrocardiography shows normal sinus rhythm.

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

Match each of the following fasting laboratory profiles, obtained during a symptomatic hypoglycemic episode, to the most likely underlying etiology. Assume normal renal and hepatic function.

Match each clinical scenario involving professional boundaries with the most appropriate ethical action or guideline.

A 42-year-old woman is brought to the emergency department by ambulance due to severe confusion, agitation, and high fever. Her husband reports she has a history of Graves' disease but stopped taking her medications three months ago. Temperature is 40.2°C (104.4°F), blood pressure is 158/68 mm Hg, and pulse is 152/min and irregularly irregular. Physical examination shows profound diaphoresis, a fine resting tremor, bilateral exophthalmos, and an enlarged, non-tender thyroid gland. An ECG confirms atrial fibrillation with rapid ventricular response. After securing the airway and initiating intravenous fluid resuscitation, the care team prepares a targeted pharmacologic regimen for her acute hypermetabolic state. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $2$-day-old female neonate is evaluated in the neonatal intensive care unit for persistent cyanosis. She was born at $39$ weeks gestation via normal vaginal delivery to a $28$-year-old primigravida. The mother has a history of bipolar disorder and was maintained on her prescribed psychiatric medication throughout the pregnancy. On physical examination, the neonate appears comfortably tachypneic but cyanotic. Vital signs show a heart rate of $160$/min, respiratory rate of $65$/min, and oxygen saturation of $82\%$ on room air. Cardiac auscultation reveals a widely split $S_1$, a normal $S_2$, and a harsh holosystolic murmur heard best at the left lower sternal border. Chest radiography demonstrates massive cardiomegaly spanning nearly the entire thoracic cavity. Electrocardiography reveals right atrial enlargement and a complete right bundle branch block. Which of the following best describes the underlying cardiovascular anomaly in this patient?

An obstetric rapid response is called for a patient at $36\text{ weeks}$ of gestation who presents to the triage unit with a $2\text{-day}$ history of worsening jaundice, persistent nausea, and severe lethargy. She has no significant past medical history, and her prenatal course was previously unremarkable. Upon evaluation, she appears visibly confused and is difficult to arouse. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $132/84\text{ mm Hg}$, and heart rate is $108/\text{min}$. Physical examination reveals scleral icterus and right upper quadrant abdominal tenderness. The uterus is soft, and pelvic examination shows a closed cervix. A continuous fetal monitor is placed, demonstrating a baseline heart rate of $145/\text{min}$ with moderate variability and spontaneous accelerations; there are no decelerations.

Initial laboratory studies are obtained and reveal the following:

Hemoglobin: $10.8\text{ g/dL}$
Platelet count: $88,000/\text{mm}^3$
Leukocyte count: $16,500/\text{mm}^3$
Glucose: $42\text{ mg/dL}$
Aspartate aminotransferase (AST): $740\text{ U/L}$
Alanine aminotransferase (ALT): $820\text{ U/L}$
Total bilirubin: $5.6\text{ mg/dL}$
Creatinine: $1.8\text{ mg/dL}$
Prothrombin time: $22\text{ seconds}$ (Reference: $11-14\text{ seconds}$)
Activated partial thromboplastin time: $54\text{ seconds}$ (Reference: $25-40\text{ seconds}$)

Intravenous dextrose is immediately administered, and the patient becomes fully oriented. Blood products are typed and crossmatched. Which of the following is the most appropriate next step in the management of this patient?

Paramedics bring a $30$-year-old patient at $37$ weeks of pregnancy to the trauma bay after a severe motor vehicle collision. Her obstetric history is notable for one prior uncomplicated vaginal delivery at term. She complains of unrelenting, severe lower abdominal pain and reports a small amount of dark red vaginal bleeding.

Vital signs show a blood pressure of $86/52$ mmHg, a heart rate of $128$/min, and a respiratory rate of $22$/min. Physical examination reveals a rigid, board-like uterus that is extremely tender to palpation. Pelvic examination demonstrates the cervix is $1$ cm dilated and $50\%$ effaced.

Continuous fetal heart rate monitoring displays a baseline of $105$/min with absent beat-to-beat variability and recurrent late decelerations occurring with every spontaneous uterine contraction. Laboratory analysis reveals a hemoglobin of $9.2$ g/dL and a normal platelet count.

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

A $32$-year-old female, currently in her second pregnancy (G2P1) at $34$ weeks of gestation, is evaluated in the emergency department for shortness of breath and leg swelling. She states that the breathlessness has gradually developed over the past few weeks and is most noticeable when she lies flat in bed. She denies chest pain, cough, or pain in her legs. Her medical history is unremarkable, and her pregnancy has been uncomplicated.

Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $112/70\text{ mmHg}$, pulse of $86\text{/min}$, and respirations of $16\text{/min}$. Oxygen saturation is $99\%$ on ambient air.

Physical examination demonstrates 1+ symmetric, bilateral pitting edema extending to the ankles. The maximum circumference of the right calf is $35.0\text{ cm}$ and the left calf is $35.5\text{ cm}$. Cardiac auscultation reveals a grade 2/6 early systolic murmur at the left sternal border. The lungs are clear to auscultation bilaterally.

Laboratory analysis reveals the following:

Hemoglobin: $10.6\text{ g/dL}$
Platelet count: $145,000\text{/mm}^3$
D-dimer: $920\text{ ng/mL}$ (Reference: $< 500\text{ ng/mL}$)

Arterial blood gas analysis on ambient air:
pH: $7.44$
PaO $_2$: $104\text{ mmHg}$
PaCO $_2$: $29\text{ mmHg}$
HCO $_3^-$: $19\text{ mEq/L}$

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

A $10$-week-old male infant is brought to the pediatric emergency department by his parents due to a $3$-day history of rapid breathing, poor feeding, and increased fussiness. The parents report that the infant takes twice as long to finish a bottle and frequently stops to catch his breath while sweating profusely over his forehead. He has had a mild cough but no fever. Medical history is notable for an uncomplicated full-term birth. A cardiac murmur was mentioned at his $1$-month well-child visit, but the family missed the follow-up appointment. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), pulse is $168/\text{min}$, respiratory rate is $68/\text{min}$, and blood pressure is $85/50\text{ mmHg}$. Pulse oximetry shows $94\%$ on room air. Physical examination reveals an infant in moderate respiratory distress with intercostal retractions. Lung auscultation reveals diffuse bilateral wheezes and fine crackles at the bases. Cardiovascular examination shows a hyperactive precordium, a loud S2, and a grade $3/6$ harsh holosystolic murmur at the left lower sternal border. The liver edge is palpated $3.5\text{ cm}$ below the right costal margin. Which of the following is the most appropriate next step in the management of this patient?

A primigravid patient at $37$ weeks of gestation is currently in the labor and delivery unit. She was admitted $24$ hours ago for induction of labor due to preeclampsia with severe features. She is receiving continuous intravenous oxytocin, labetalol, and magnesium sulfate. Over the past $4$ hours, her total urine output has been $45\text{ mL}$. The nurse calls the physician because the patient has become increasingly somnolent and difficult to arouse. Current vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $135/85\text{ mmHg}$, pulse $82/\text{min}$, and respiratory rate $8/\text{min}$. Oxygen saturation is $90\%$ on room air. Neurologic examination reveals absent deep tendon reflexes at the patella and biceps. The continuous fetal heart rate tracing demonstrates a baseline of $145/\text{min}$, minimal variability, and no decelerations. Which of the following is the most appropriate initial step in management?

An $8$-month-old girl is brought to a family medicine clinic in mid-December due to a persistent cough and noisy breathing. Her mother reports that the child developed a runny nose, low-grade fever, and mild nasal congestion four days ago. Yesterday, the nasal discharge became thick, and the child developed a "tight" cough. She has no prior episodes of wheezing and was born at term without complications. She has been feeding well and producing a normal number of wet diapers. Vital signs are temperature $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), heart rate $125\text{/min}$, respiratory rate $44\text{/min}$, and oxygen saturation $96\%$ on room air. Physical examination reveals a happy, interactive infant. Lung auscultation demonstrates diffuse bilateral expiratory wheezes and mild subcostal retractions. Which of the following interventions are appropriate components of the immediate management plan for this patient? (Select all that apply)

During a routine health maintenance visit, a 54-year-old G2P2 patient reports experiencing two days of light vaginal spotting the previous week. She underwent natural menopause at age 51. Her past medical history is significant for estrogen receptor-positive, node-negative breast cancer, for which she was treated with a lumpectomy and radiation therapy three years ago. Since completing her primary surgical and radiation treatment, she has been maintained on tamoxifen. Her body mass index is 26 kg/m^2. Vital signs are within normal limits. Pelvic examination demonstrates normal external genitalia, a small and mobile uterus, and no palpable adnexal masses. Speculum examination shows a small amount of dark red blood in the vaginal vault, but no active bleeding or visible cervical lesions. Which of the following is the most appropriate next step in management?

An obstetric team is attending the delivery of a macrosomic infant at 40 weeks gestation. After the fetal head emerges, it immediately retracts tightly against the mother's perineum. The anterior shoulder remains impacted behind the pubic symphysis despite routine gentle downward traction. Arrange the following management steps in the correct standard sequence of escalation to resolve this complication, from the immediate first response to the maneuver of last resort.

An adolescent primigravida at 39 weeks gestation is currently in the active phase of labor following spontaneous rupture of membranes 24 hours ago. Over the last hour, she has developed a new-onset fever. She is currently receiving continuous epidural analgesia. Her temperature is 39.2°C (102.6°F), blood pressure is 112/70 mm Hg, pulse is 115/min, and respirations are 18/min. Physical examination reveals a uterus that is tender to palpation between contractions. Pelvic examination shows the cervix is 6 cm dilated and 90% effaced, with the fetal presenting part at +1 station. Uterine contractions are occurring every 5 to 6 minutes. Continuous fetal monitoring displays a baseline heart rate of 175/min with moderate variability and occasional early decelerations. Which of the following is the most appropriate next step in the management of this patient?