All practice questions

A $48$-year-old woman comes to the primary care clinic reporting a $3$-month history of progressively worsening weakness. She specifically notes difficulty climbing the stairs to her bedroom and rising from a low chair. Over the past several weeks, she has also experienced mild difficulty swallowing solid foods. She denies any muscle pain, joint swelling, or morning stiffness. Vital signs are within normal limits. Physical examination reveals symmetric $3/5$ strength in the deltoids and hip flexors, with $5/5$ strength in the distal extremities. There is a violaceous periorbital discoloration accompanied by mild edema, as well as erythematous, scaly plaques over the metacarpophalangeal joints. Deep tendon reflexes are $2+$ and symmetric. Laboratory studies show a creatine kinase level of $3,200$ U/L.

Based on this clinical presentation, arrange the following differential diagnoses from the highest pre-test probability (most likely) to the lowest pre-test probability (least likely).

A 33-year-old female healthcare worker presents to the ambulatory care clinic due to progressive central weight gain and menstrual irregularities ongoing for the last eight months. The patient works as a triage nurse on a schedule that requires three rotating night shifts per week. Her medical history is unremarkable, and she takes a daily combined oral contraceptive pill. Vital signs show a blood pressure of 145/92 mm Hg and a heart rate of 78/min. Physical examination reveals facial plethora, significant accumulation of adipose tissue around the abdomen and posterior neck, and several wide, violaceous striae on the lower abdominal flanks. Proximal muscle weakness is noted when she attempts to stand from a seated position without using her arms. The physician strongly suspects endogenous hypercortisolism. Which of the following is the most appropriate initial step in laboratory evaluation?

A 32-year-old woman is brought to the emergency department by her husband due to severe confusion, profuse vomiting, and a racing heart over the past 24 hours. She has a known history of Graves disease but discontinued her antithyroid medications three months ago. Her temperature is 40.5°C (104.9°F), blood pressure is 90/55 mm Hg, pulse is 155/min, and respirations are 26/min. The patient is agitated, visibly tremulous, and disoriented to time and place. Cardiopulmonary examination reveals a regular, rapid rhythm and clear lungs. She is warm and profoundly diaphoretic. She is immediately placed on a continuous cardiac monitor and provided supplemental oxygen.

Arrange the following management steps in the most appropriate chronological sequence for the safe initial stabilization and treatment of this patient's acute condition.

A $72$-year-old man presents to the outpatient clinic for a routine follow-up. He reports that his home blood pressure readings have been consistently elevated in the $160$/$90 \text{ mm Hg}$ range over the past two months. His blood pressure was previously well-controlled on a stable regimen of lisinopril, amlodipine, and hydrochlorothiazide. He reports mild, worsening bilateral ankle swelling but denies chest pain, shortness of breath, or changes in urination. His past medical history is significant for essential hypertension, hyperlipidemia, and severe osteoarthritis of the knees. His surgical history includes an appendectomy in childhood. He drinks one glass of wine occasionally and has never smoked. Upon questioning, he reports adhering strictly to his prescribed medications and maintaining a low-sodium diet. He mentions that he started taking an over-the-counter naproxen twice daily three months ago for his knee pain because acetaminophen was no longer effective. Today, his blood pressure in the clinic is $168$/$96 \text{ mm Hg}$, and his pulse is $76\text{ /min}$. Laboratory studies show a serum creatinine of $1.5 \text{ mg/dL}$ (baseline $1.0 \text{ mg/dL}$ six months ago) and a serum potassium of $4.8 \text{ mEq/L}$.

Based on the medical history, which of the following is the most likely underlying mechanism for this patient's current clinical presentation?

A 58-year-old man presents to the clinic complaining of a "fluttering" sensation in his chest and mild shortness of breath upon exertion that started 3 days ago. He has no prior medical history and takes no medications. Vital signs show a blood pressure of 130/80 mmHg, a pulse of 115/min and irregularly irregular, a respiratory rate of 16/min, and an oxygen saturation of 98% on ambient air. Physical examination reveals no murmurs, normal breath sounds, and no lower extremity edema. A 12-lead electrocardiogram demonstrates absent P waves and irregularly irregular R-R intervals with a ventricular rate of 118/min. Which of the following diagnostic tests are indicated as part of the routine initial workup for this patient? (Select all that apply)

A thorough medical history must actively query the use of over-the-counter products, dietary supplements, and herbal remedies, as these agents can cause severe direct organ toxicity or dangerous drug interactions. Match the following specific patient historical profiles emphasizing botanical supplement use to the most appropriate diagnostic consideration or clinical syndrome.

A 68-year-old man is brought to the emergency department by his wife due to worsening mid-back pain, fever, and progressive weakness in his legs over the past 3 days. For the past 12 hours, he has been unable to urinate. His medical history is significant for type 2 diabetes mellitus, hypertension, and sick sinus syndrome, for which a dual-chamber permanent pacemaker was placed 15 years ago. His temperature is 38.8°C (101.8°F), blood pressure is 148/88 mm Hg, pulse is 76/min, and respirations are 16/min. Physical examination reveals exquisite tenderness to percussion over the T8-T10 spinous processes. Neurologic examination shows 3/5 motor strength in the bilateral lower extremities, decreased pain and temperature sensation below the umbilicus, and absent Achilles reflexes. Post-void residual bladder volume is measured at 650 mL. Laboratory studies show a leukocyte count of 16,500/mm³ and an erythrocyte sedimentation rate of 85 mm/h. Which of the following is the most appropriate next step in imaging for this patient?

A 28-year-old woman presents to the preoperative clinic for medical clearance prior to an elective septoplasty. During the clinical interview, she mentions having heavy menstrual periods that frequently require changing pads every 2 hours during the first three days of her cycle. She also recalls an incident at age 18 when a wisdom tooth extraction resulted in continuous oozing of blood for over 24 hours, requiring a return visit to the oral surgeon for suturing and packing. She has no history of spontaneous joint swelling or gastrointestinal bleeding. Her medical history is significant only for mild iron deficiency anemia, for which she takes an over-the-counter iron supplement. She takes no other medications and does not use nonsteroidal anti-inflammatory drugs. Vital signs are within normal limits. Physical examination reveals no petechiae, ecchymoses, or hepatosplenomegaly. Preoperative laboratory testing shows:

Hemoglobin: 11.8 g/dL
Platelet count: 240,000/mm³
Prothrombin time (PT): 11 seconds (Reference: 11-15 seconds)
Activated partial thromboplastin time (aPTT): 28 seconds (Reference: 25-40 seconds)

Based on the patient's medical history, which of the following is the most appropriate next step in evaluation?

A 65-year-old woman with a documented 45-pack-year smoking history and advanced chronic obstructive pulmonary disease presents to her outpatient clinic complaining of new-onset abdominal fullness and progressive swelling in both lower legs over the past three weeks. She denies paroxysmal nocturnal dyspnea, orthopnea, or recent changes in her chronic daily cough. Her vital signs are temperature 37.1°C (98.8°F), blood pressure 122/78 mm Hg, pulse 92/min, and respiratory rate 18/min. Pulse oximetry shows 89% on room air. Based on the patient's most likely primary underlying cardiovascular complication, which of the following physical examination findings are expected? (Select exactly two)

A patient in the cardiac intensive care unit is noted to have a rapidly declining platelet count on morning laboratories. He was admitted 6 days prior for a non-ST-segment elevation myocardial infarction, for which he underwent percutaneous coronary intervention and received continuous unfractionated heparin infusion for 48 hours. Currently, he is on subcutaneous heparin for deep vein thrombosis prophylaxis. His admission platelet count was $240,000/\text{mm}^3$. Today's routine complete blood count reveals a platelet count of $95,000/\text{mm}^3$. The patient is asymptomatic, with no petechiae, ecchymoses, or active bleeding. Hemoglobin is $13.5 \text{ g/dL}$ and leukocyte count is $7,500/\text{mm}^3$. Vital signs are stable. Which of the following is the most appropriate next step in laboratory evaluation?

A series of adult patients present to the pulmonology clinic with varying presentations of chronic dyspnea and cough. Match each patient's clinical vignette with the most likely corresponding high-resolution computed tomography (HRCT) imaging pattern.

A 54-year-old woman is evaluated in the outpatient continuity clinic for a 4-month history of worsening fatigue, joint stiffness in her hands, and a recurrent rash on her lower legs. The rash consists of small, raised, red-to-purple spots that do not blanch when pressed. She also notes intermittent "pins and needles" sensations in her toes.

Medical history is significant for hypertension and hypothyroidism. Surgical history includes an open reduction and internal fixation of a femur fracture following a severe motor vehicle collision in 1989. She takes lisinopril and levothyroxine. She does not use tobacco or illicit drugs and drinks 1-2 glasses of wine weekly.

Vital signs are within normal limits. Skin examination reveals palpable purpura over the bilateral distal lower extremities. The metacarpophalangeal joints are mildly tender without frank swelling. Neurologic examination shows decreased pinprick sensation in the bilateral toes. The liver edge is palpated 3 cm below the right costal margin.

Laboratory results are as follows:
White blood cell count: $6,500/\mu\text{L}$
Hemoglobin: $11.2\text{ g/dL}$
Platelets: $145,000/\mu\text{L}$
Aspartate aminotransferase (AST): $82\text{ U/L}$
Alanine aminotransferase (ALT): $95\text{ U/L}$
Creatinine: $1.4\text{ mg/dL}$
Urinalysis: 2+ protein, 10-15 RBCs/hpf
Rheumatoid factor: Positive
Complement C3: Normal
Complement C4: Low

Which of the following additional historical questions is most essential to establishing the underlying etiology of this patient's current condition?

A 52-year-old man presents to the clinic with a 3-month history of progressively worsening shortness of breath, abdominal swelling, and lower extremity edema. Fifteen years ago, he was treated with mantle field radiation therapy for Hodgkin lymphoma. His temperature is 37.0°C (98.6°F), blood pressure is 112/76 mmHg, pulse is 98/min, and respiratory rate is 18/min. Physical examination reveals marked jugular venous distention. Upon deep inspiration, the jugular veins become further distended. Lung fields are clear to auscultation bilaterally. Abdominal examination demonstrates shifting dullness and a liver edge palpable 4 cm below the right costal margin. Bilateral 2+ pitting edema is noted up to the knees. Which of the following additional physical examination findings is most likely to be present in this patient?

Emergency medical services transport a 62-year-old male to the resuscitation bay following the abrupt onset of excruciating, anterior chest pain that radiates directly to his upper back. The patient describes the pain as "ripping" in quality. He has a history of long-standing, non-adherent hypertension. On arrival, he is lethargic but arousable, pale, and profusely diaphoretic. Vital signs include a heart rate of $124/min$, a respiratory rate of $24/min$, and a blood pressure of $78/45\text{ mm Hg}$. Physical examination reveals a prominent early diastolic decrescendo murmur auscultated over the right second intercostal space. His left radial pulse is weak and delayed, while the right is bounding. The initial 12-lead electrocardiogram indicates sinus tachycardia without ischemic ST-segment changes. Large-bore intravenous lines are secured, and fluid resuscitation is initiated. Which of the following is the single most appropriate initial imaging modality to establish the diagnosis?

A 32-year-old woman with a history of type 1 diabetes mellitus is brought to the emergency department by her husband due to altered mental status and 3 days of severe nausea, recurrent vomiting, and generalized abdominal pain. She has been unable to retain any oral intake and missed her last three doses of insulin.

On physical examination, her temperature is 37.1°C (98.8°F), blood pressure is 98/60 mm Hg, pulse is 122/min, and respirations are 24/min and deep. Her mucous membranes are remarkably dry, and skin turgor is decreased. Her breath has a fruity odor.

Laboratory studies show:
Serum sodium: $140 \text{ mEq/L}$
Serum potassium: $4.1 \text{ mEq/L}$
Serum chloride: $92 \text{ mEq/L}$
Serum bicarbonate: $14 \text{ mEq/L}$
Serum glucose: $540 \text{ mg/dL}$
Serum BUN: $45 \text{ mg/dL}$
Serum creatinine: $1.9 \text{ mg/dL}$
Serum ketones: Positive

Arterial blood gas on room air:
pH: 7.28
$\text{PaCO}_2$: $29 \text{ mmHg}$
$\text{PaO}_2$: $98 \text{ mmHg}$

Assuming a normal reference serum anion gap of $12 \text{ mEq/L}$ and a normal reference serum bicarbonate of $24 \text{ mEq/L}$, what is the calculated delta ratio ($\Delta\text{AG} / \Delta\text{HCO}_3^-$) for this patient?

Paramedics transport a young female to the triage area following a syncopal episode at her workplace. The patient, who is 31 years of age, reports that prior to fainting, she experienced an abrupt onset of excruciating pain in the lower right side of her abdomen. Her medical background is unremarkable. Upon assessment in the resuscitation bay, her skin is remarkably pale and clammy. Evaluation of her vital parameters demonstrates a core temperature of 36.8°C (98.2°F), a markedly diminished blood pressure of 74/42 mm Hg, a pulse of 142/min, and respirations of 22/min. Her oxygen saturation remains 98% while breathing ambient air. She is conversing, though she appears confused and drowsy. Auscultation of the thorax is clear. Palpation of the abdomen elicits diffuse tenderness, significant guarding, and rebound, with the point of maximum intensity in the lower right quadrant. Which of the following is the single most urgent initial step in the management of this patient?

A physician is evaluating four patients in the immunology and rheumatology clinic who present with distinct clinical syndromes. Match each patient's clinical presentation with the most appropriate targeted laboratory testing to help establish the diagnosis.

A 42-year-old male presents to the urgent care clinic complaining of sudden-onset, sharp left lower quadrant abdominal pain that began 12 hours ago. He denies nausea, vomiting, fevers, chills, or changes in bowel habits. His medical history is unremarkable, and he takes no medications. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 124/80 mm Hg, heart rate of 78/min, and respiratory rate of 14/min. Physical examination reveals a non-distended abdomen with focal tenderness to deep palpation in the left lower quadrant. There is no guarding or rebound tenderness. Laboratory studies reveal a leukocyte count of 7,500/mm³ and a completely normal comprehensive metabolic panel. A contrast-enhanced computed tomography scan of the abdomen and pelvis reveals a 2.5-cm, oval-shaped, fat-attenuating lesion with a hyperdense peripheral rim abutting the anterior wall of the descending colon. Mild inflammatory stranding is seen surrounding the lesion. The appendix and colonic wall appear normal, and there is no evidence of diverticulosis. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in management?

A 28-year-old man of Southeast Asian descent presents to the primary care clinic complaining of mild, intermittent fatigue over the past six months. He has no other symptoms, and his past medical history is unremarkable. He follows a strict vegan diet and takes no supplements. Vital signs are within normal limits. Physical examination is notable only for mild conjunctival pallor. The physician suspects an underlying hematologic abnormality and plans a stepwise laboratory evaluation.

Arrange the following diagnostic laboratory tests in the most appropriate chronological sequence to definitively evaluate the etiology of this patient's presentation, from initial screening to definitive confirmation.

A 68-year-old man comes to the clinic for a follow-up examination for difficult-to-control hypertension. He was diagnosed with hypertension 15 years ago. For the past year, his blood pressure has been consistently greater than 160/100 mm Hg despite documented adherence to maximum tolerated doses of amlodipine, metoprolol, and chlorthalidone. One week ago, his physician added lisinopril to his regimen. His medical history is also significant for type 2 diabetes mellitus, hyperlipidemia, and peripheral artery disease characterized by bilateral calf claudication. Today, his blood pressure is 178/98 mm Hg and heart rate is 72/min. Physical examination reveals diminished pulses in the lower extremities and a right-sided abdominal bruit. Laboratory studies from two weeks ago showed a serum creatinine of 1.1 mg/dL. Today, his serum creatinine is 1.9 mg/dL and serum potassium is 4.8 mEq/L. Which of the following is the most appropriate next step in the diagnostic workup?