All practice questions

Review the clinical vignettes and laboratory profiles below. Match each patient's clinical presentation and laboratory pattern to the most likely underlying primary endocrine diagnosis.

A 62-year-old man is hospitalized for right lower lobe pneumococcal pneumonia. After 72 hours of targeted intravenous antibiotic therapy, he has persistent fevers, tachypnea, and pleuritic chest pain. A chest radiograph reveals a new, moderate-to-large, free-flowing right-sided pleural effusion.

Assuming each subsequent intervention indicates the need for further escalation due to inadequate clinical resolution or complex fluid characteristics, arrange the following management steps in the most appropriate chronological sequence.

A 72-year-old woman is evaluated in the outpatient clinic for a 4-day history of frequent, watery, foul-smelling diarrhea and mild lower abdominal cramping. She has a medical history of chronic obstructive pulmonary disease (COPD) and diet-controlled type 2 diabetes mellitus. Three weeks ago, she completed a course of oral clindamycin for a dental abscess. She currently feels fatigued but denies shortness of breath, cough, or weight loss. Her temperature is 38.0°C (100.4°F), blood pressure is 118/76 mm Hg, and pulse is 92/min. Physical examination reveals mild, diffuse lower abdominal tenderness with hyperactive bowel sounds; there is no guarding or rebound tenderness. Which of the following is the most appropriate next step in management?

A 72-year-old woman is admitted to the hospital with a 2-day history of fever, severe right upper quadrant abdominal pain, and dark urine. Her temperature is 39.2°C (102.6°F), blood pressure is 94/60 mmHg, and pulse is 112/min. Physical examination reveals scleral icterus and marked right upper quadrant tenderness without rebound or guarding. Laboratory studies show a leukocyte count of 18,500/mm³ and a total bilirubin of 6.2 mg/dL. Abdominal ultrasound demonstrates a dilated common bile duct with an echogenic focus and acoustic shadowing. She is resuscitated with intravenous fluids and empirically started on intravenous piperacillin-tazobactam. An urgent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is performed, successfully removing a common bile duct stone and establishing biliary drainage. Two sets of blood cultures drawn upon admission subsequently grow *Escherichia coli*. Susceptibility testing reveals the organism is sensitive to ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole, but resistant to amoxicillin. On hospital day 3, the patient is afebrile, hemodynamically stable, and her leukocytosis has resolved. Which of the following is the most appropriate next step in management regarding her antibiotic therapy?

A 62-year-old woman is evaluated in the outpatient clinic for a 3-day history of worsening shortness of breath, increased cough, and a change in sputum color from clear to dark yellow. She has a history of chronic obstructive pulmonary disease (COPD) and typically uses an albuterol inhaler as needed. Her temperature is 37.4°C (99.3°F), blood pressure is 130/82 mm Hg, pulse is 96/min, and respirations are 20/min. Pulse oximetry is 93% on room air. Physical examination reveals a barrel-shaped chest and a prolonged expiratory phase with scattered bilateral wheezing. There is no jugular venous distention, and no lower extremity edema is present. In addition to optimizing her bronchodilator therapy and initiating a short course of oral corticosteroids, which of the following is the most appropriate next step in management?

A 14-month-old boy is brought to the pediatrician for a well-child visit. His parents report that he has been developing normally and has met all his developmental milestones on time. Arrange the following gross motor milestones in the chronological order in which this patient most likely achieved them, from earliest to latest.

Following $2$ days of fever, progressive confusion, and abdominal pain, a $55$-year-old man is brought to the emergency department. He has a known history of alcohol-associated cirrhosis and diuretic-refractory ascites, for which he takes furosemide and spironolactone. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $88/54$ mm Hg, pulse is $112$/min, and respirations are $24$/min. Physical examination reveals scleral icterus, a distended abdomen with shifting dullness, and diffuse abdominal tenderness to palpation. Asterixis is present.

Laboratory studies show:
Sodium: $140$ mEq/L
Potassium: $2.9$ mEq/L
Chloride: $105$ mEq/L
Bicarbonate: $20$ mEq/L
Blood urea nitrogen: $42$ mg/dL
Creatinine: $1.9$ mg/dL
Albumin: $1.0$ g/dL
Lactate: $5.2$ mmol/L

Arterial blood gas on room air:
pH: $7.51$
PaCO $_2$: $26$ mm Hg
PaO $_2$: $85$ mm Hg

Which of the following best characterizes this patient's primary acid-base disturbances?

A 60-year-old man suddenly collapses while walking in the hospital lobby. He is found to be unresponsive, pulseless, and apneic. Bystanders immediately begin high-quality chest compressions. An automated external defibrillator (AED) is attached, and the rhythm monitor displays ventricular fibrillation. Arrange the following subsequent interventions in the correct chronological order according to standard Advanced Cardiovascular Life Support (ACLS) guidelines.

Match the following sets of laboratory profiles to the most likely underlying pathophysiologic diagnosis. Assume all patients have normal renal function (serum creatinine 0.7-1.0 mg/dL). Reference ranges: Serum calcium 8.4-10.2 mg/dL; Serum phosphate 2.7-4.5 mg/dL; Intact PTH 10-65 pg/mL; 24-hr urine calcium 100-300 mg.

A series of patients undergo diagnostic paracentesis for newly developed or worsening ascites. Based on the provided laboratory and clinical findings, match each patient's ascitic fluid profile with the most accurate underlying pathophysiologic mechanism and diagnosis.

An otherwise healthy 29-year-old fitness instructor presents for medical evaluation due to a one-month history of a racing heart, heat intolerance, and shakiness. She notes that she has been taking multiple non-prescription nutritional supplements to accelerate fat loss for an upcoming bodybuilding competition. Vital signs demonstrate a blood pressure of 135/75 mm Hg and a heart rate of 112/min. Physical examination reveals a fine tremor in her outstretched hands, hyperreflexia, and warm, moist skin. There is no exophthalmos, and her thyroid gland is nonpalpable.

Laboratory studies show the following:

Which of the following is the most likely diagnosis?

A 52-year-old man is brought to the emergency department by ambulance after being found obtunded in his garage. His medical history is significant for major depressive disorder and alcohol use disorder. He is unresponsive to verbal stimuli but localizes to pain. Vital signs are within normal limits except for a respiratory rate of $24/\text{min}$. Laboratory evaluation reveals the following:

Arterial blood gas on room air shows a pH of $7.22$, $PCO_2$ of $26 \text{ mm Hg}$, and $PO_2$ of $92 \text{ mm Hg}$.

Based on these laboratory results, what is the patient's calculated serum osmolar gap?

A 66-year-old man presents to the emergency department with the sudden onset of severe, tearing chest pain that radiates to his back. He appears diaphoretic and in severe distress. Blood pressure is 188/112 mm Hg in the right arm and 156/94 mm Hg in the left arm. Pulse is 112/min and bounding. Cardiac auscultation reveals a new decrescendo diastolic murmur at the right upper sternal border. An electrocardiogram shows sinus tachycardia with no ST-segment or T-wave changes. Suspecting an acute aortic syndrome, the physician prepares to manage the patient.

Arrange the following next steps in the most appropriate chronological order for the initial stabilization and management of this patient.

A 55-year-old male with long-standing hepatic cirrhosis presents to the emergency department via ambulance due to a large episode of hematemesis. On arrival, his blood pressure is 88/50 mm Hg and pulse is 120/min. The physical examination reveals a distended abdomen with shifting dullness and prominent cutaneous telangiectasias. Arrange the following interventions in the correct chronological sequence for the management of this patient.

Emergency medical services bring a 65-year-old male to the resuscitation bay following the sudden onset of profound shortness of breath and altered mentation. The patient's wife states these symptoms began abruptly one hour ago while he was watching television. His medical history is notable for severe chronic obstructive pulmonary disease (COPD) managed with home oxygen therapy. Four days ago, he suffered an inferior ST-segment elevation myocardial infarction and was treated with percutaneous coronary intervention of the right coronary artery.

On physical examination, the patient is obtunded, diaphoretic, and using accessory muscles of respiration. Jugular venous pulsations are visible up to 11 cm $\text{H}_2\text{O}$. Auscultation of the chest reveals widespread coarse crackles and prolonged expiratory wheezing. Cardiac auscultation is significant for a hyperdynamic precordium and a new, loud, grade 4/6 holosystolic murmur heard loudest at the apex that radiates to the left axilla.

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

A medical student is reviewing the typical progression of motor development in early childhood. Arrange the following gross motor milestones in the chronological order in which they typically emerge in a healthy, full-term infant.

A 68-year-old man presents to the clinic with a 4-month history of progressive dysphagia to both solid foods and liquids. He reports frequent episodes of regurgitating undigested, bland-tasting food shortly after meals and occasionally wakes up coughing at night. He has experienced an unintentional weight loss of 13 kg (28.6 lb) during this period. Medical history is significant for hypertension and a 45-pack-year smoking history. Vital signs are within normal limits. Physical examination reveals temporal wasting but is otherwise unremarkable. A barium esophagram demonstrates significant dilation of the proximal and mid-esophagus with a smooth, tapering 'bird's beak' appearance at the lower esophageal sphincter. Esophageal manometry shows aperistalsis of the esophageal body and absent relaxation of the lower esophageal sphincter. Upper gastrointestinal endoscopy reveals a normal-appearing esophageal mucosa; however, the endoscopist encounters firm resistance at the esophagogastric junction, and the endoscope cannot be advanced into the stomach despite gentle pressure. Which of the following is the most appropriate next step in management?

A 62-year-old woman comes to the urgent care clinic complaining of worsening shortness of breath over the last 2 days. She has a 40-pack-year smoking history and was diagnosed with chronic obstructive pulmonary disease (COPD) 5 years ago. She uses a daily fluticasone/salmeterol inhaler and a tiotropium inhaler. Her home oxygen saturation is usually 93% on room air. Over the past 48 hours, she has noticed increased cough and a larger volume of sputum, which remains clear to white. She has had no fever, orthopnea, or lower extremity edema. Temperature is 37.0°C (98.6°F), blood pressure is 134/82 mm Hg, pulse is 96/min, and respirations are 22/min. Pulse oximetry is 91% on room air. Pulmonary examination shows a prolonged expiratory phase with scattered wheezes bilaterally. Cardiovascular examination is normal with no murmurs, gallops, or jugular venous distention. There is no peripheral edema. Which of the following is the most appropriate next step in management?

Emergency medical services bring a 69-year-old retired teacher to the resuscitation bay due to three days of worsening respiratory distress. She reports an increase in sputum production that has become dark yellow. Her medical history is significant for hypertension, diet-controlled type 2 diabetes, and a 45-pack-year smoking history.

On physical examination, she is alert and cooperative but visibly exhausted, sitting on the edge of the stretcher and leaning forward on her arms. Temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), pulse is $112/\text{min}$, respirations are $28/\text{min}$, and blood pressure is $155/88\text{ mm Hg}$. Pulse oximetry shows an oxygen saturation of $85\%$ on room air. Jugular venous pulsation is visible $4\text{ cm}$ above the sternal angle. Chest auscultation reveals a prolonged expiratory phase with diffuse polyphonic wheezes and faint basilar crackles. Mild bilateral pitting edema is present at the ankles.

An electrocardiogram shows sinus tachycardia with right axis deviation and peaked P waves in lead II. A chest radiograph demonstrates hyperinflated lung fields, flattened hemidiaphragms, and enlarged central pulmonary arteries without focal consolidation.

Relevant laboratory results are as follows:

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

A $38$-year-old man is brought to the emergency department by emergency medical services after his roommate found him unresponsive. The roommate reports that the patient was severely depressed about a recent job loss and had been drinking a large amount of homemade, illicitly distilled liquor (moonshine). On arrival, the patient is difficult to arouse. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $105/65$ mm Hg, pulse is $92$/min, and respiratory rate is $8$/min.

Laboratory results are as follows:
Sodium: $142$ mEq/L
Potassium: $4.8$ mEq/L
Chloride: $102$ mEq/L
Bicarbonate: $12$ mEq/L

Arterial blood gas analysis on room air reveals:
pH: $7.12$
$\text{PaO}_2$: $65$ mm Hg
$\text{PaCO}_2$: $38$ mm Hg

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