All practice questions

A 72-year-old retired teacher arrives at the emergency department accompanied by her spouse. She complains of acute onset lightheadedness, chest pressure, and a sensation of her heart "racing" that began an hour ago while watching television. She has a history of hypertension and osteoarthritis. On assessment, she is pale and visibly sweating. She answers questions but appears confused and lethargic. Temperature is 36.8°C (98.2°F), heart rate is 172/min, blood pressure is 68/40 mm Hg, respiratory rate is 22/min, and oxygen saturation is 94% on room air. The cardiac monitor reveals a narrow-complex, irregularly irregular rhythm without discernible P waves. Which of the following is the most urgent next step in the management of this patient?

A 55-year-old man presents to his primary care physician reporting a single episode of red-colored urine yesterday. He denies any flank pain, dysuria, urinary frequency, fever, or trauma. His medical history is notable for a 35 pack-year smoking history, and he worked as an industrial painter for 20 years. His blood pressure is 135/85 mmHg, and heart rate is 78/min. Physical examination, including a digital rectal examination, is unremarkable. Urinalysis reveals 60 red blood cells per high-power field, 1-2 white blood cells per high-power field, and no leukocyte esterase or nitrites. Serum creatinine is 1.0 mg/dL. He is referred to a urologist for cystoscopy. Which of the following is the most appropriate imaging study to complete the diagnostic evaluation of this patient?

A 34-year-old woman is evaluated in the emergency department for right-sided neck pain and a severe headache that began abruptly 4 hours ago while stretching her neck during a yoga class. She also reports drooping of her right eyelid. Her medical history is significant for type 1 diabetes mellitus complicated by advanced diabetic nephropathy, with a baseline estimated glomerular filtration rate of 22 mL/min/1.73 m². She takes insulin glargine and insulin lispro. Vital signs are temperature 37.0°C (98.6°F), blood pressure 138/85 mm Hg, pulse 88/min, and respirations 16/min. Neurologic examination reveals right-sided ptosis and miosis. Extraocular movements are intact, and there is no facial weakness, dysarthria, or extremity weakness. Sensation is intact globally. A stat non-contrast computed tomography of the head reveals no intracranial hemorrhage or established infarct. Which of the following is the most appropriate next imaging study for this patient?

Match each patient presentation with the most likely underlying etiology of their acute kidney injury based on their clinical history and diagnostic findings.

Match each clinical presentation and corresponding non-contrast head computed tomography (CT) finding to the most likely diagnosis.

Five patients present to the nephrology service with varying degrees of acute kidney injury, edema, and hematuria. Normal complement reference ranges are C3 $90-180\text{ mg/dL}$ and C4 $10-40\text{ mg/dL}$. Based on the distinct serologic and urinalysis profiles provided, pair each laboratory pattern with its correct clinical diagnosis.

A 42-year-old woman is evaluated on the inpatient medical ward for acute-onset agitation, confusion, and severe diaphoresis. She was admitted 2 days ago for a complicated right lower extremity skin abscess, for which she was started on intravenous linezolid. Her past medical history is significant for major depressive disorder, which has been managed with fluoxetine for the past three years. Vital signs show a temperature of 38.9°C (102.0°F), blood pressure of 165/95 mmHg, pulse of 124/min, and respiratory rate of 20/min. Physical examination reveals a flushed, profusely diaphoretic patient who appears restless and continuously shifts in bed. Neurologic examination demonstrates bilateral 4+ patellar reflexes, sustained ankle clonus, and a bilateral resting tremor. Bowel sounds are hyperactive. She is immediately given intravenous normal saline and lorazepam, and her current antimicrobial and antidepressant medications are discontinued. Which of the following is the most appropriate next pharmacologic intervention for this patient's current condition?

An emergency medical services team brings a 68-year-old male to the hospital after he lost consciousness while walking up a flight of stairs. Witnesses state that he collapsed suddenly without any preceding diaphoresis, palpitations, or visual changes. He regained full alertness within approximately one minute and had no post-event confusion. His blood pressure is 112/82 mm Hg and his heart rate is 76/min. Cardiac auscultation reveals a harsh, late-peaking systolic murmur at the right upper sternal border that radiates to the neck. Palpation of the carotid arteries demonstrates a delayed and diminished upstroke. The neurological examination is completely unremarkable. Which of the following diagnostic studies are indicated as the initial concurrent steps in this patient's evaluation? (Select exactly two)

A 62-year-old man is evaluated in the intensive care unit for a sudden-onset cardiopulmonary deterioration. He was admitted three days ago for severe community-acquired pneumonia and acute respiratory distress syndrome (ARDS), requiring endotracheal intubation and positive pressure mechanical ventilation. Over the past 15 minutes, the ventilator alarms for high peak airway pressures. His heart rate increases from 95/min to 135/min, and his blood pressure drops from 110/70 mm Hg to 82/50 mm Hg. Oxygen saturation is 84% on a fraction of inspired oxygen ($FiO_2$) of 0.80. Physical examination reveals distended neck veins and diminished breath sounds over the right hemithorax. A stat portable anteroposterior chest radiograph obtained in the supine position reveals an abnormally radiolucent right costophrenic angle that extends much deeper than the left, without a clearly visible visceral pleural line at the apex. Which of the following is the most appropriate next step in management based on these imaging findings?

A $26$-year-old woman is evaluated in the hematology clinic for a history of easy bruising, frequent epistaxis, and heavy menstrual bleeding since menarche. She reports that a recent tooth extraction resulted in oozing that lasted for $2$ days. She has no history of joint swelling or deep muscle pain. She takes no medications and does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Physical examination shows several small ecchymoses on the upper and lower extremities but no petechiae, jaundice, or hepatosplenomegaly.

Laboratory studies show:
Hemoglobin: $11.4 \text{ g/dL}$
Mean corpuscular volume: $78 \text{ fL}$
Platelet count: $260,000/\text{mm}^3$
Prothrombin time (PT): $11 \text{ seconds}$
Activated partial thromboplastin time (aPTT): $46 \text{ seconds}$ (normal: $25-35 \text{ seconds}$)

A mixing study with normal plasma completely corrects the aPTT to $30 \text{ seconds}$.

Based on the clinical presentation and laboratory findings, which of the following is the most likely diagnosis?

A 62-year-old woman is evaluated in the emergency department for progressive fatigue, exertional dyspnea, and bilateral tingling in her feet over the past three months. She has a history of hypothyroidism treated with levothyroxine and a remote history of Roux-en-Y gastric bypass surgery.

Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate $105\text{/min}$, blood pressure $110/70\text{ mmHg}$, and respiratory rate $16\text{/min}$. Physical examination reveals conjunctival pallor and mild scleral icterus. Neurologic examination demonstrates decreased vibratory and position sensation in the bilateral lower extremities.

Laboratory results are as follows:

Based on the interpretation of these laboratory results, which of the following is the most likely underlying mechanism for this patient's presentation?

A 48-year-old woman is evaluated in the clinic following a minor motor vehicle collision $2$ weeks ago. During her emergency department visit, a computed tomography (CT) scan of the abdomen and pelvis without contrast was performed to evaluate right-sided abdominal pain. The scan revealed no acute intra-abdominal injuries, but an incidental $2.8$ cm, well-circumscribed, homogeneous mass with an attenuation of $8$ Hounsfield units was identified in the right adrenal gland. The patient reports she feels well and has fully recovered from her mild abdominal wall contusion. She has no history of headaches, palpitations, episodic sweating, unexplained weight gain, or muscle weakness. Her medical history is significant for essential hypertension diagnosed $3$ years ago, which is well-controlled with amlodipine. She takes no other medications. Vital signs are a blood pressure of $128/82$ mmHg, a heart rate of $74$/min, and a BMI of $25 \text{ kg/m}^2$. Physical examination reveals no abdominal bruits, purple striae, facial plethora, or central adiposity. Which of the following is the most appropriate next step in the diagnostic workup for this patient's adrenal finding?

An adult with end-stage renal disease is evaluated in the emergency department for severe generalized weakness after missing three consecutive hemodialysis sessions. A 12-lead electrocardiogram demonstrates widened QRS complexes and tall, peaked T waves. The care team prepares to initiate urgent medical therapy while awaiting emergency hemodialysis.

Arrange the following pharmacologic interventions in the correct chronological sequence of administration, from the most immediate therapeutic priority to the final step in management.

A 31-year-old man is evaluated in the surgical ward for severe right lower extremity pain. He was admitted four hours ago after sustaining a closed, comminuted fracture of the right tibial midshaft in a motorcycle collision. A posterior plaster splint was applied in the emergency department. The patient now reports rapidly worsening, burning pain in his right leg that is not relieved by intravenous hydromorphone. The pain is out of proportion to his initial injury. On physical examination, the right leg appears visibly swollen, and the compartments are tense to palpation. The physician suspects a developing orthopedic emergency. Which of the following specific physical examination findings is the most reliable early indicator to establish this diagnosis before irreversible tissue damage occurs?

A 65-year-old man with a history of poorly controlled hypertension presents to the emergency department with sudden-onset, severe, 'tearing' chest pain that radiates to his back between his scapulae. His blood pressure is 185/110 mmHg in the right arm and 145/90 mmHg in the left arm. A new decrescendo diastolic murmur is heard at the right upper sternal border. An acute type A aortic dissection is suspected. Arrange the following imaging modalities in the typical chronological order they are indicated for the initial triage, definitive preoperative evaluation, intraoperative management, and long-term outpatient surveillance of this patient.

Emergency medical services arrive at the hospital with a 28-year-old female patient who is highly agitated and delirious. According to her family, she has a documented history of Graves disease but abandoned her prescribed medical therapy three months prior. Her temperature is 39.8°C (103.6°F), heart rate is 155/min, blood pressure is 160/70 mm Hg, and respiratory rate is 24/min. Physical examination reveals a diaphoretic patient with a diffusely enlarged, non-tender thyroid gland and a marked resting tremor. An electrocardiogram shows sinus tachycardia. Arrange the following pharmacologic interventions in the most appropriate chronological sequence for the acute management of this patient's condition.

A physician is evaluating four patients presenting with varying respiratory symptoms and specific systemic manifestations. Match each patient's clinical presentation with the most appropriate targeted laboratory evaluation required to establish the definitive diagnosis.

A 65-year-old man is admitted to the hospital with worsening dyspnea and a large unilateral pleural effusion. Diagnostic thoracentesis is performed to analyze the pleural fluid. Match each pleural fluid laboratory profile to its most likely underlying clinical etiology.

A $78$-year-old woman is evaluated in the emergency department for severe, diffuse abdominal pain that began suddenly $3$ hours ago. She has a history of atrial fibrillation, hypertension, and type 2 diabetes mellitus. She stopped taking apixaban two months ago due to financial difficulties. On physical examination, she appears distressed and diaphoretic. Temperature is $38.1^\circ C$ ($100.6^\circ F$), pulse is $122/min$ and irregularly irregular, blood pressure is $90/60$ $mm Hg$, and respirations are $24/min$. Abdominal examination reveals a slightly distended abdomen that is soft, with only mild tenderness to deep palpation and no rebound or guarding. Bowel sounds are diminished. Laboratory studies show a leukocyte count of $18,500/mm^3$ and serum lactate of $5.2$ $mmol/L$. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis is performed. The radiologist's report notes an abrupt filling defect in the superior mesenteric artery, along with linear radiolucencies tracking parallel to the wall of the small bowel and branching tubular radiolucencies extending to the periphery of the liver. Based on the described imaging findings, which of the following is the most appropriate next step in management?

For each patient presentation and associated radiological imaging description below, select the most accurate diagnosis.