All practice questions

A 48-year-old woman comes to the emergency department due to a 24-hour history of severe, colicky abdominal pain, nausea, and bilious vomiting. She has not passed flatus or stool since the pain began. Her medical history is notable for a laparoscopic appendectomy 10 years ago. She takes no daily medications. Her temperature is 37.3°C (99.1°F), blood pressure is 114/76 mm Hg, pulse is 106/min, and respirations are 18/min. Physical examination reveals an asymmetrically distended abdomen. It is highly tympanitic to percussion and moderately tender diffusely, but there is no guarding or rebound tenderness. Bowel sounds are high-pitched and hyperactive. A plain radiograph of the abdomen demonstrates a markedly dilated, comma-shaped loop of bowel originating in the right lower quadrant and projecting toward the left upper quadrant. There is a single air-fluid level within the loop and a paucity of gas in the distal colon. Which of the following is the most appropriate next step in management?

A 62-year-old male is evaluated in the surgical intensive care unit on postoperative day 8 following an open appendectomy for a perforated appendix. After an initially uncomplicated recovery with return of bowel function on day 4, he developed severe, constant abdominal pain, nausea, and bilious vomiting over the past 24 hours. He has not passed flatus since the onset of these symptoms.

His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is $125/\text{min}$, respiratory rate is $24/\text{min}$, and blood pressure is $88/55\text{ mmHg}$.

Physical examination reveals a distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent.

Laboratory studies show a leukocyte count of $19,500/\text{mm}^3$ with $85\%$ neutrophils, and a serum lactate of $4.6 \text{ mmol/L}$.

Supine and upright abdominal radiographs demonstrate multiple dilated loops of small bowel with prominent air-fluid levels and a paucity of colonic gas.

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

A 67-year-old man is evaluated on hospital day 3. He was initially admitted for fever, chills, and left flank pain. His past medical history is significant for a T10 spinal cord injury resulting in neurogenic bladder, managed with intermittent clean catheterization. On presentation to the emergency department, his temperature was $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure was $92/58\text{ mmHg}$, and heart rate was $114/\text{min}$. Laboratory testing demonstrated a leukocyte count of $16,500/\text{mm}^3$. He was aggressively resuscitated with intravenous fluids and empirically started on intravenous piperacillin-tazobactam and vancomycin for presumed urosepsis.

Today, the patient's temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $122/78\text{ mmHg}$, and heart rate is $82/\text{min}$. He has been afebrile for the last 36 hours and is tolerating a normal oral diet. His flank pain has resolved. The urine culture collected on admission has finalized, growing $>10^5\text{ CFU/mL}$ of *Enterococcus faecalis*. Susceptibility testing results are as follows:

Blood cultures drawn on admission show no growth after 48 hours. Which of the following is the most appropriate next step in the patient's antimicrobial management?

A $68$-year-old woman is evaluated on hospital day $3$. She was initially admitted to the intensive care unit with fever, right upper quadrant pain, jaundice, and hypotension. On admission, her temperature was $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure was $88/54\text{ mmHg}$, and heart rate was $118\text{/min}$. Laboratory studies showed a leukocyte count of $18,500/\mu\text{L}$, total bilirubin of $6.2\text{ mg/dL}$, and alkaline phosphatase of $450\text{ U/L}$. She was resuscitated with intravenous fluids, started on empiric intravenous piperacillin-tazobactam, and underwent emergent endoscopic retrograde cholangiopancreatography (ERCP), which revealed purulent bile and a common bile duct stone. A biliary sphincterotomy with stone extraction was performed successfully.

Today, she is transferred to the general medical floor. She is afebrile and hemodynamically stable, and her abdominal pain has resolved. Blood cultures drawn on admission now grow *Escherichia coli*. Susceptibility testing demonstrates that the organism is resistant to ampicillin but susceptible to ceftriaxone, cefepime, ciprofloxacin, meropenem, and piperacillin-tazobactam.

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

A 32-year-old female, gravida 1, para 0, at 35 weeks gestation, is brought to the trauma center following a high-speed motor vehicle collision. She was a restrained passenger. On arrival, she is lethargic, confused, and oriented only to her name. Her husband, who was driving and sustained minor injuries, is present in the trauma bay and demands that the medical team focus exclusively on saving the fetus. A card discovered in the patient's wallet legally designates her sister as her healthcare proxy.

Evaluation reveals a patent airway and symmetric vesicular breath sounds bilaterally. Vital signs include a heart rate of 142/min, respiratory rate of 26/min, and blood pressure of 76/40 mm Hg. Pulse oximetry is 98% on room air. The patient is placed on a backboard with manual left uterine displacement. An initial fluid bolus is administered with minimal hemodynamic improvement.

Extended focused assessment with sonography for trauma (E-FAST) demonstrates a large anechoic collection in the splenorenal recess. There is no evidence of pneumothorax. Fetal heart rate monitoring demonstrates a baseline of 105/min with minimal variability and recurrent late decelerations.

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

A 48-year-old man is brought to the clinic by his sister due to a 5-month history of progressive forgetfulness, social withdrawal, and difficulty concentrating. The sister reports that he takes an unusually long time to answer simple questions and that his walking has become slow and uncoordinated. His medical history is significant for HIV infection, diagnosed 12 years ago. He admits to poor adherence to his antiretroviral therapy over the past 18 months. His most recent CD4+ T-cell count was 145/mm³. Vital signs are within normal limits. Neurological examination reveals marked psychomotor slowing, saccadic pursuit eye movements, and brisk deep tendon reflexes in the bilateral lower extremities. His Montreal Cognitive Assessment score is 19/30. Magnetic resonance imaging of the brain demonstrates diffuse cortical atrophy and symmetric, bilateral periventricular white matter hyperintensities without contrast enhancement or mass effect. Which of the following is the most likely diagnosis?

Following an assault, a 29-year-old woman is evaluated in the emergency department for a deep stab wound to the right side of her neck. On arrival, she is confused and diaphoretic. Her blood pressure is 80/40 mmHg and her pulse is 130/min. Physical examination reveals an actively expanding, pulsatile hematoma in the right anterior cervical triangle. There is a continuous stream of bright red blood oozing through the applied pressure dressing. The patient's airway remains patent and breath sounds are bilateral. Which of the following is the most appropriate next step in management?

A 28-year-old woman is brought to the emergency department after falling from a fourth-story balcony. She was intubated at the scene due to a depressed level of consciousness. Upon arrival, her temperature is 36.1°C (97.0°F), blood pressure is 72/40 mm Hg, and pulse is 138/min. Physical examination reveals a 7-mm, nonreactive right pupil and a 3-mm, briskly reactive left pupil. The trachea is midline, and breath sounds are present and equal bilaterally. The pelvis is stable to anteroposterior and lateral compression. The left thigh is visibly swollen and deformed. Focused assessment with sonography for trauma (FAST) demonstrates an anechoic stripe in the hepatorenal recess. A peripheral intravenous line is established, and 1 L of warmed lactated Ringer solution is rapidly infused; her blood pressure remains 70/40 mm Hg. Which of the following is the most appropriate next step in the management of this patient?

A 39-year-old woman comes to the emergency department due to a 24-hour history of high fever, chills, and right-sided back pain. She also reports a constant sensation of vaginal wetness that requires her to change her sanitary pad multiple times a day. Ten days ago, the patient underwent an uncomplicated total abdominal hysterectomy for severe endometriosis. Her temperature is 39.0°C (102.2°F), blood pressure is 110/65 mmHg, and pulse is 112/min. She has no pain with urination and voids normally. Physical examination shows pronounced tenderness to percussion over the right costovertebral angle. On speculum examination, a pool of clear fluid is visualized in the vaginal vault. The vaginal cuff appears well-approximated without erythema. A transurethral catheter is placed, and a retrograde instillation of a dilute methylene blue solution into the bladder is performed. A sterile tampon placed in the vagina for 15 minutes is subsequently removed; it is saturated with clear, yellowish fluid but shows no evidence of blue discoloration. Which of the following is the most appropriate next step in management?

A 61-year-old retired engineer is brought to the physician by his daughter for a psychiatric evaluation. Over the past five weeks, he has become increasingly withdrawn, spending most of the day in bed. He reports waking up at 3:00 AM daily and being unable to return to sleep. His daughter notes he has lost approximately 5.5 kg (12 lb) during this period and no longer shows interest in his usual hobbies, such as gardening. Two weeks ago, the patient's primary care provider diagnosed him with a major depressive episode and prescribed fluoxetine. The patient states he feels no better and wants to discontinue the medication. Upon further questioning, the daughter recalls that when her father was in his late thirties, he was briefly given a different antidepressant for sadness. Within days of starting that medication, he became excessively talkative, slept only two hours a night for a week, and impulsively bought three luxury vehicles, leading to a brief psychiatric hospitalization. Medical history is otherwise unremarkable, and he takes no other medications. Vital signs are within normal limits. Which of the following is the most appropriate next step in management?

A 22-year-old male is brought to the emergency department via ambulance after being kicked directly in the abdomen by a horse. On arrival, he is groggy but follows simple commands. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, and pulse is 132/min. Oxygen saturation is 99% on room air. Large-bore intravenous access is established, and 1 liter of crystalloid fluid is rapidly administered. Following the fluid bolus, his blood pressure remains low at 82/45 mm Hg. Physical examination reveals a large contusion over the epigastrium. The abdomen is markedly distended with diffuse rebound tenderness and involuntary guarding. A focused assessment with sonography for trauma (FAST) exam demonstrates a large amount of free fluid in the hepatorenal recess and the splenorenal recess. Which of the following is the most appropriate next step in management?

A $58$-year-old male is evaluated in the hospital on hospital day $3$. He was initially admitted for worsening abdominal distension, lethargy, and confusion. He has a past medical history of alcoholic cirrhosis and esophageal varices. On admission, his temperature was $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure was $105/65\text{ mmHg}$, and pulse was $92/\text{min}$. Physical examination revealed scleral icterus, spider angiomas, a prominent fluid wave, and mild, diffuse abdominal tenderness. Laboratory studies on admission showed:

A diagnostic paracentesis yielded hazy fluid with a leukocyte count of $750/\text{mm}^3$ and $80\%$ polymorphonuclear cells. Due to a prolonged hospitalization for a variceal bleed one month prior, he was empirically started on intravenous piperacillin-tazobactam.

Today, his mental status has returned to baseline, and his abdominal discomfort has resolved. Ascitic fluid cultures from admission have grown *Escherichia coli*. Susceptibility testing shows the isolate is resistant to ciprofloxacin but sensitive to ceftriaxone, cefotaxime, piperacillin-tazobactam, and meropenem. Which of the following is the most appropriate next step in the pharmacologic management of this patient's infection?

A 74-year-old man is brought to the emergency department due to sudden-onset, severe abdominal pain that began 2 hours ago. He has a medical history of chronic obstructive pulmonary disease, heart failure with preserved ejection fraction, and paroxysmal atrial fibrillation. He recently stopped taking his prescribed apixaban. The patient reports nausea and one episode of vomiting. He also complains of mild shortness of breath. Temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $150/90 \text{ mmHg}$, pulse is $118\text{ /min}$ and irregularly irregular, and respirations are $22\text{ /min}$. Pulse oximetry is $94\%$ on room air. Lung auscultation reveals scattered end-expiratory wheezes. The abdomen is soft and non-distended; there is mild, diffuse tenderness to palpation, but no rebound or guarding. Bowel sounds are decreased. Laboratory studies show:

Leukocyte count: $16,500/\text{mm}^3$
Lactic acid: $3.8 \text{ mmol/L}$
Thyroid-stimulating hormone (TSH): $0.3 \mu\text{U/mL}$ (N: $0.4-4.0 \mu\text{U/mL}$)

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

A 58-year-old woman is evaluated in the outpatient clinic for a six-month history of progressive abdominal bloating, frequent flatulence, and chronic watery diarrhea. She also reports a 4.5-kg (10-lb) weight loss over this period despite maintaining a normal appetite. Her past medical history is notable for Raynaud phenomenon and systemic sclerosis, for which she is taking mycophenolate mofetil. Vital signs are within normal limits. Physical examination reveals thickened, tight skin over the fingers and face, as well as mild, diffuse abdominal distension without focal tenderness or organomegaly. Laboratory studies are obtained and reveal the following:

Hemoglobin: 10.4 g/dL
Mean corpuscular volume: 106 fL
Vitamin B12: 120 pg/mL (low)
Folate: 26 ng/mL (abnormally high)

Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's gastrointestinal symptoms?

A 52-year-old man presents to the clinic reporting progressively worsening swelling in his lower extremities and profound daytime fatigue over the past four months. His wife, who accompanies him, notes that he frequently falls asleep during conversations and snores loudly at night. His medical history includes obesity, essential hypertension, and diet-controlled type 2 diabetes mellitus. He has no history of tobacco use.

Vital signs show a temperature of $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), heart rate of $88/\text{min}$, blood pressure of $135/85\text{ mmHg}$, respiratory rate of $14/\text{min}$, and oxygen saturation of $89\%$ on room air. BMI is $42\text{ kg/m}^2$.

Physical examination reveals prominent jugular venous distention with noticeable *a* waves. Cardiac auscultation demonstrates a right ventricular heave, a loud pulmonic component of the second heart sound ($P_2$), and a holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. The lungs are clear to auscultation bilaterally. Bilateral $3+$ pitting edema is present up to the knees.

Laboratory studies show:
Hemoglobin: $16.8\text{ g/dL}$
Thyroid-stimulating hormone (TSH): $2.5\text{ \mu U/mL}$ (Normal: $0.4-4.0\text{ \mu U/mL}$)
Free T4: $1.2\text{ ng/dL}$ (Normal: $0.9-1.7\text{ ng/dL}$)

An arterial blood gas analysis obtained on room air reveals:
pH: $7.37$
$\text{PaCO}_2$: $56\text{ mmHg}$
$\text{PaO}_2$: $60\text{ mmHg}$
$\text{HCO}_3^-$: $31\text{ mEq/L}$

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

A 56-year-old man is admitted to the hospital with a 2-day history of diffuse abdominal pain, nausea, and progressive lethargy. He has a history of alcohol-associated cirrhosis and portal hypertension. On presentation, his temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, heart rate is $98/\text{min}$, and respiratory rate is $20/\text{min}$. Physical examination shows scleral icterus, spider angiomata, and moderate abdominal distension with shifting dullness. There is diffuse abdominal tenderness but no rebound or guarding. Bowel sounds are hypoactive. Asterixis is present. Arterial blood gas analysis on room air reveals the following:

Diagnostic paracentesis is performed, and ascitic fluid analysis shows:

Gram stain of the fluid shows no organisms.

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

A $31$-year-old woman, G1P0, at $26$ weeks gestation is brought to the emergency department due to acute-onset severe shortness of breath, palpitations, and an episode of coughing up blood-tinged sputum. Her symptoms began abruptly $2$ hours ago. Over the past two months, she has experienced progressive fatigue and mild exertional dyspnea, which she attributed to her pregnancy. She emigrated from Southeast Asia five years ago and has not had consistent medical care. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $108/68$ mmHg, heart rate is $145$/min and irregularly irregular, respiratory rate is $28$/min, and oxygen saturation is $89\%$ on room air. Jugular venous pressure is elevated. The apical impulse is not displaced. Cardiac auscultation reveals a loud first heart sound, an early diastolic high-frequency sound, and a low-pitched mid-diastolic rumble at the apex. Bilateral fine crackles are heard in the lower two-thirds of the lung fields.

Laboratory results are as follows:
- Hemoglobin: $11.2$ g/dL
- Leukocyte count: $10,500$/mm $^3$
- Thyroid-stimulating hormone (TSH): $0.3$ mIU/L
- Free T4: $1.2$ ng/dL

Electrocardiography shows absent P waves, irregularly irregular R-R intervals, and right axis deviation. Which of the following is the most appropriate initial pharmacological intervention for this patient?

A 42-year-old man presents to the emergency department complaining of sharp, severe chest pain that began yesterday. He states that the pain is significantly worse when he breathes deeply or lies flat on his back, but it improves when he sits up and leans forward. He reports having had a mild upper respiratory infection with a sore throat one week ago. His temperature is 37.6°C (99.7°F), blood pressure is 120/80 mm Hg, heart rate is 95/min, respiratory rate is 16/min, and oxygen saturation is 99% on room air. Auscultation of the chest reveals a high-pitched, scratchy, three-component sound heard best at the left lower sternal border. An electrocardiogram (ECG) is obtained and shows diffuse, concave-upward ST-segment elevations and PR-segment depressions across multiple leads. Which of the following is the most appropriate initial treatment for this patient?

A male patient, aged $58$, presents to the emergency department complaining of a $3$-day history of fever, chills, and severe left knee swelling. He has a past medical history significant for type $2$ diabetes mellitus but denies any recent falls or joint trauma. Initial vital signs reveal a temperature of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure of $110/70\text{ mm Hg}$, and heart rate of $112/\text{min}$. Physical examination highlights a warm, intensely erythematous, and exquisitely tender left knee with a noticeable effusion.

Arthrocentesis is performed, yielding frankly purulent synovial fluid with a leukocyte count of $85,000/\text{mm}^3$ ($90\%$ neutrophils). Blood and synovial fluid cultures are obtained, and he is empirically started on intravenous vancomycin and ceftriaxone before undergoing urgent arthroscopic lavage.

On hospital day $3$, the patient demonstrates clinical improvement and is currently afebrile. The microbiology laboratory reports that both the synovial fluid and blood cultures are growing *Staphylococcus aureus*. Susceptibility testing demonstrates that the isolate is resistant to penicillin but susceptible to oxacillin, cefazolin, and clindamycin. The patient's allergy profile notes a mild, non-pruritic maculopapular rash that occurred after taking amoxicillin during childhood; he has never experienced anaphylaxis, angioedema, or respiratory compromise associated with any medication.

Which of the following is the most appropriate antimicrobial regimen for this patient going forward?

A $4$-day-old female newborn is brought to the outpatient clinic for a routine follow-up examination. She was delivered at term ($38$ weeks gestation) via an uncomplicated vaginal birth and is exclusively breastfed. Her mother reports that the infant struggles to latch onto the breast and often falls asleep after only a few minutes of nursing. Over the past $24$ hours, the infant has produced only $2$ wet diapers and continues to pass dark, sticky stools. On physical examination, the infant appears lethargic with dry oral mucous membranes and a slightly sunken anterior fontanelle. Scleral icterus is present, and jaundice extends to her upper chest. Her current weight is $2.85$ kg, which represents an $11\%$ decrease from her birth weight of $3.20$ kg.

Laboratory studies reveal the following:

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