All practice questions

During morning rounds on the medical ward, a consulting physician evaluates a patient admitted overnight for persistent fever, generalized weakness, and dark urine. The patient was seen at an urgent care center one week ago for an erythematous, expanding annular rash with central clearing on the right thigh following a camping trip in Massachusetts. Oral doxycycline was initiated at that time. Although the rash has faded, the patient reports worsening systemic symptoms. Current vital signs include a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure of $110/70 \text{ mmHg}$, and a heart rate of $112/\text{min}$. Physical examination is notable for scleral icterus and mild splenomegaly. Laboratory findings show a hemoglobin level of $7.8 \text{ g/dL}$, platelet count of $95,000/\text{mm}^3$, elevated indirect bilirubin, and significantly elevated lactate dehydrogenase. A peripheral blood smear reveals pleomorphic intraerythrocytic organisms, with occasional tetrad formations. Which of the following is the most appropriate modification to this patient's antimicrobial regimen?

A $45$-year-old woman is evaluated in the clinic for a $4$-month history of constant palpitations, excessive sweating, and a $6\text{-kg}$ ($13.2\text{-lb}$) weight loss despite a significantly increased appetite. She also reports new, persistent bi-frontal headaches and recently sideswiped a vehicle while driving, stating she "did not see the car in the next lane." Physical examination reveals warm, moist skin, a fine resting tremor of the outstretched hands, and a diffusely enlarged, non-tender thyroid gland without palpable nodules. Confrontational visual field testing demonstrates diminished peripheral vision bilaterally. Vital signs show a heart rate of $110/\text{min}$ and blood pressure of $145/85\text{ mm Hg}$. A urine pregnancy test is negative.

Laboratory results are as follows:
- Thyroid-stimulating hormone (TSH): $5.8\text{ mU/L}$ (Normal: $0.5\text{ - }5.0\text{ mU/L}$)
- Free thyroxine (T4): $3.2\text{ ng/dL}$ (Normal: $0.9\text{ - }1.7\text{ ng/dL}$)
- Free triiodothyronine (T3): $6.5\text{ pg/mL}$ (Normal: $2.0\text{ - }4.4\text{ pg/mL}$)

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

A 62-year-old man is admitted to the intensive care unit with septic shock secondary to severe pneumonia. He remains hypotensive despite adequate intravenous fluid resuscitation and requires vasopressor support. Laboratory studies are obtained to evaluate his acid-base status.

Based on the provided laboratory results, what is the patient's calculated serum anion gap?

A $54$-year-old man is admitted to the intensive care unit directly from the medical triage area due to high fever and altered mental status. His wife reports that he has been complaining of painful urination and flank discomfort for three days. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $82/48 \text{ mm Hg}$, heart rate is $130\text{/min}$, and respiratory rate is $30\text{/min}$. Physical examination shows a lethargic man with mottling of the lower extremities and marked suprapubic tenderness.

Laboratory results:
Serum sodium: $140 \text{ mEq/L}$
Serum potassium: $4.5 \text{ mEq/L}$
Serum chloride: $104 \text{ mEq/L}$
Serum bicarbonate: $16 \text{ mEq/L}$
Blood urea nitrogen: $32 \text{ mg/dL}$
Serum creatinine: $1.6 \text{ mg/dL}$

Arterial blood gas (room air):
pH: $7.45$
pCO $_2$: $24 \text{ mm Hg}$
pO $_2$: $88 \text{ mm Hg}$

What is the most accurate description of this patient's acid-base disorder?

Match each clinical presentation of a pediatric exanthem with its most likely causative viral pathogen.

A 42-year-old male is brought to the emergency department after falling 20 feet from a roof. He is groaning and does not open his eyes or follow commands. Blood is visible in his oropharynx, and he has gurgling respirations. His respiratory rate is 28/min. Breath sounds are absent on the right side, and his trachea is deviated to the left. His blood pressure is 80/40 mm Hg, and his heart rate is 135/min. Arrange the following management steps in the correct chronological order according to Advanced Trauma Life Support primary survey priorities.

Correlate the following clinical presentations of acute intrapartum and third-trimester emergencies with their primary defining pathophysiologic mechanism.

A $4$-year-old boy is evaluated in the genetics clinic due to developmental delay and behavioral changes. His parents report that his early milestones were met on time, but over the past year, he has become increasingly hyperactive, aggressive, and his speech has regressed. Physical examination reveals a child with coarse facial features, a prominent forehead, and a widened nasal bridge. Abdominal examination demonstrates a liver edge palpable $4 \text{ cm}$ below the right costal margin and a palpable spleen. Musculoskeletal examination shows joint stiffness with decreased range of motion in the elbows, wrists, and knees. An ophthalmologic evaluation reveals clear corneas bilaterally without evidence of clouding. Which of the following is the most likely diagnosis?

An emergency response team brings a 59-year-old woman to the resuscitation bay after she experienced a sudden onset of profound weakness and severe breathlessness at home. Her past medical history is significant for advanced non-small cell lung cancer and severe chronic obstructive pulmonary disease. On arrival, her blood pressure is 82/54 mm Hg, heart rate is 124/min, and respiratory rate is 26/min. Oxygen saturation is 94% on 2 L/min via nasal cannula. Physical examination reveals prominent jugular venous distention. The lung fields have scattered end-expiratory wheezes, but no crackles are heard. Cardiac auscultation demonstrates distant, muffled heart sounds. The patient's radial pulse is weak, and its amplitude noticeably diminishes during inspiration. Which of the following is the most appropriate next step in the management of this patient?

A 35-year-old man comes to the clinic for a routine 6-month sexually transmitted infection screening. He is currently asymptomatic and has no somatic complaints. He reports having multiple male sexual partners. He has no known drug allergies and takes a daily tenofovir-emtricitabine regimen for HIV pre-exposure prophylaxis.

His medical history is significant for a diagnosis of primary syphilis $2$ years ago, which was appropriately treated with a single intramuscular injection of benzathine penicillin G. At the time of that diagnosis, his Rapid Plasma Reagin (RPR) titer was $1:64$. Six months after his treatment, the titer had decreased to $1:2$.

Review of his medical records shows that during his last routine screening $6$ months ago, his RPR titer remained stable at $1:2$.

Today, his physical examination is unremarkable, with no evidence of chancre, mucosal lesions, maculopapular rash, or neurological abnormalities.

Laboratory results from today's visit:
HIV antigen/antibody test: Negative
RPR: Positive, titer $1:32$
*Treponema pallidum* particle agglutination (TP-PA): Positive

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

Match each clinical presentation of a trauma patient to the most appropriate next step in management or diagnostic imaging.

Match each primary acid-base disorder to its corresponding expected physiological compensatory response.

A 75-year-old man presents to the emergency department with acute-onset, severe dyspnea that woke him from sleep. He has a history of a myocardial infarction 5 years ago and a 45-pack-year smoking history. His blood pressure is 165/95 mmHg, heart rate is 112/min, and respiratory rate is 28/min. Pulse oximetry is 88% on room air. He is visibly distressed, sitting on the edge of the stretcher, and coughing up pink, frothy sputum. Pulmonary auscultation reveals diffuse bilateral wheezes and scattered crackles. Which of the following physical examination findings would most strongly support a primary cardiac etiology for this patient's acute respiratory distress over a primary pulmonary exacerbation?

A 42-year-old woman is evaluated in the post-anesthesia care unit $2$ hours after undergoing a total thyroidectomy for a multinodular goiter. The nursing staff calls urgently because the patient has developed acute respiratory distress. She is agitated, diaphoretic, and exhibits pronounced inspiratory stridor. Her oxygen saturation is $84\%$ on room air. Physical examination reveals a tense, rapidly expanding swelling beneath the cervical incision. Arrange the following management steps in the most appropriate chronological sequence for this patient's life-threatening complication, assuming each step is performed if the previous intervention fails to completely resolve the airway compromise.

A 48-year-old male is evaluated in the emergency department after experiencing an abrupt onset of agonizing, diffuse abdominal pain that started two hours ago. He reports that the discomfort is continuous and severely worsens with any physical movement. His medical history is significant for chronic osteoarthritis, which is managed with high-dose daily naproxen, and he is a current tobacco user. He recently noted a gnawing upper abdominal ache that would temporarily improve after meals. Currently, he is lying motionless on the examination table and taking shallow breaths. Vital signs indicate a temperature of 37.9°C (100.2°F), a pulse of 118/min, and a blood pressure of 105/65 mm Hg. Abdominal assessment is notable for board-like rigidity, generalized rebound tenderness, and absent bowel sounds. An upright chest radiograph reveals a distinct crescent of free air below the right hemidiaphragm. Following initial fluid resuscitation, which of the following is the most appropriate next step in management?

Paramedics bring a 72-year-old man to the emergency department due to a 1-day history of severe dyspnea and increasing somnolence. His medical history includes severe chronic obstructive pulmonary disease (COPD) requiring continuous home oxygen, heart failure with a left ventricular ejection fraction of $35\%$, and essential hypertension. Upon arrival, his temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $165/95$ mm Hg, heart rate is $118$/min, and respiratory rate is $28$/min. Oxygen saturation is $84\%$ on his baseline $2$ L/min via nasal cannula. He is lethargic but arouses to loud verbal stimuli. Physical examination reveals an elevated jugular venous pressure of $13$ cm $H_2O$. Lung auscultation demonstrates diffuse, bilateral expiratory wheezing and prominent bibasilar fine crackles. Cardiac auscultation reveals a regular tachycardia with a distinct third heart sound ($S_3$). There is $2+$ bilateral pitting edema of the lower extremities. Laboratory studies show a leukocyte count of $8,500/mm^3$. An arterial blood gas analysis obtained on $2$ L/min of oxygen reveals:

$pH$: $7.22$
$PaCO_2$: $72$ mm Hg
$PaO_2$: $52$ mm Hg
$HCO_3^-$: $30$ mEq/L

A trial of noninvasive positive pressure ventilation (NIPPV) is immediately initiated. Which of the following is the most appropriate additional next step in the management of this patient?

Match each patient's clinical presentation with the most appropriate antimicrobial stewardship-guided management step.

A 55-year-old man is brought to the emergency department by his wife due to progressively worsening shortness of breath and lethargy over the past week. His wife reports he recently had a mild viral upper respiratory tract infection and has been falling asleep mid-conversation for the past two days. His medical history is significant for morbid obesity, hypertension, and type 2 diabetes mellitus. He has a 5-pack-year smoking history but quit 15 years ago.

Vital signs are:
Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
Pulse: $98\text{/min}$
Blood pressure: $145/90\text{ mmHg}$
Respiratory rate: $22\text{/min}$
$SpO_2$: $84\%$ on room air
BMI: $46\text{ kg/m}^2$

Physical examination shows a somnolent but easily arousable obese man. Jugular venous pulsation is visible $9\text{ cm}$ above the sternal angle. Chest auscultation reveals shallow, distant breath sounds bilaterally with no crackles or wheezes. Cardiac examination shows a regular rhythm with a prominently split second heart sound and a loud pulmonic component ($P_2$). The abdomen is protuberant. There is 3+ pitting edema of the bilateral lower extremities extending to the knees.

Laboratory results reveal a leukocyte count of $8,500/\mu\text{L}$ and a B-type natriuretic peptide (BNP) level of $110\text{ pg/mL}$ (normal: $<100\text{ pg/mL}$). Chest radiography shows an enlarged main pulmonary artery but clear lung fields without infiltrates, effusions, or cardiomegaly.

Arterial blood gas analysis on room air reveals:
pH: $7.31$
$PaCO_2$: $62\text{ mmHg}$
$PaO_2$: $55\text{ mmHg}$
$HCO_3^-$: $31\text{ mEq/L}$

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

A 45-year-old woman is being evaluated for progressive weight gain, proximal muscle weakness, and easy bruising. Physical examination reveals central adiposity, wide purple abdominal striae, facial plethora, and a blood pressure of 160/100 mmHg. The physician suspects Cushing syndrome. Assuming each step dictates the need for the subsequent one to identify an occult etiology, arrange the following diagnostic procedures in the correct sequential order, from initial confirmation to final localization.

Match each esophageal motility disorder with its most characteristic finding on high-resolution esophageal manometry.