All practice questions

A 35-year-old woman is referred to the clinic for evaluation of resistant hypertension. Her blood pressure today is 168/105 mmHg despite documented medication adherence to maximum tolerated doses of amlodipine, lisinopril, and hydrochlorothiazide. She reports experiencing frequent, discrete episodes of severe throbbing headaches, profound diaphoresis, and a racing heart over the last three months. Her BMI is 23 kg/m^2. Physical examination is unremarkable, with no abdominal bruits, violaceous striae, or abnormal fat distribution. Laboratory studies reveal a serum potassium of 4.1 mEq/L and a serum creatinine of 0.8 mg/dL.

Arrange the following differential diagnoses for her secondary hypertension from MOST likely to LEAST likely based on her specific clinical presentation.

A triage physician evaluates a 42-year-old man who complains of severe, progressively worsening mid-back pain over the past 5 days. He states the pain wakes him from sleep and is poorly responsive to over-the-counter analgesics. The patient has a history of opioid use disorder and currently injects heroin. During the past 24 hours, he has noticed progressive weakness in both legs and an inability to urinate. Vital signs reveal a temperature of 38.3°C (100.9°F), heart rate of 105/min, blood pressure of 118/76 mm Hg, and respiratory rate of 18/min. Neurologic examination demonstrates 3/5 strength in the proximal and distal muscle groups of both lower extremities. Sensation to pinprick is decreased below the umbilicus. Patellar and Achilles reflexes are 3+ bilaterally, and a positive Babinski sign is present on the right. Point-of-care bladder ultrasound reveals 500 mL of retained urine. Which of the following diagnostic studies should be ordered concurrently as the initial workup for this patient? (Select exactly 3)

A 58-year-old postmenopausal woman presents to the clinic for evaluation of a newly identified right breast lump. She noticed the firm, painless mass in the upper outer quadrant 2 weeks ago during self-examination. Physical examination confirms a 2-centimeter, non-tender, relatively mobile mass in the right breast with no overlying skin dimpling, nipple retraction, or axillary lymphadenopathy. Her last screening mammogram was 18 months ago and was reported as normal. Arrange the following diagnostic steps in the most appropriate chronological sequence for the evaluation of this patient's new palpable mass.

A 68-year-old man presents to the ambulatory care clinic with a 1-day history of severe pain, swelling, and redness in his left knee. The pain began abruptly and is exacerbated by any movement or weight-bearing. His medical history is significant for long-standing hypertension, type 2 diabetes mellitus, and stage 4 chronic kidney disease with a recent estimated glomerular filtration rate of $22 \text{ mL/min/1.73 m}^2$. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $142/85 \text{ mmHg}$, and heart rate of $82\text{/min}$. Physical examination reveals a warm, erythematous, and swollen left knee with a detectable effusion. Arthrocentesis is performed. Synovial fluid analysis reveals a leukocyte count of $35,000\text{/mm}^3$ (predominantly neutrophils). Gram stain is negative, and polarized light microscopy demonstrates numerous needle-shaped, negatively birefringent crystals. Which of the following is the most appropriate pharmacologic intervention for this patient's acute symptoms?

A 28-year-old woman with a 4-year history of ulcerative colitis presents to the emergency department with a 3-day history of progressively worsening abdominal pain and frequent, large-volume bloody diarrhea. Over the past 24 hours, she has also developed chills and profound weakness. Her current medications include mesalamine, which she states she stopped taking a month ago. Her temperature is 39.2°C (102.6°F), blood pressure is 92/58 mmHg, pulse is 128/min, and respirations are 22/min. Physical examination reveals a markedly distended abdomen that is diffusely tender to palpation with voluntary guarding. Percussion demonstrates severe tympany, and bowel sounds are absent. Laboratory studies show a leukocyte count of 18,500/mm³ and a hemoglobin of 9.2 g/dL. Which of the following is the most appropriate initial imaging study to evaluate this patient's current condition?

During a routine primary care visit, a 68-year-old woman describes a six-month history of steadily worsening balance and difficulty performing fine motor tasks, such as fastening the buttons on her clothing. She mentions that her hands feel increasingly 'clumsy,' leading to frequently dropping objects, and she has fallen twice while navigating her kitchen. Her medical background includes long-standing type 2 diabetes mellitus, hypertension, and osteoarthritis. Neurologic evaluation reveals intact cranial nerves and 4/5 strength in the intrinsic muscles of both hands. Which of the following physical examination findings would specifically support the most likely diagnosis of her condition? (Select all that apply)

A 45-year-old man comes to the outpatient clinic reporting a 6-month history of worsening joint pain, generalized fatigue, and excessive sweating. He mentions that he had to have his wedding ring enlarged twice over the past year due to changes in his hands. His past medical history is significant for type 2 diabetes mellitus, which was diagnosed three months ago. Blood pressure is 152/94 mm Hg, heart rate is 78/min, and BMI is 29 kg/m $^2$. Physical examination reveals an enlarged, prominent jaw, macroglossia, and enlarged, doughy hands. Which of the following is the most appropriate next step in laboratory evaluation?

Following a minor fall resulting in right-sided chest wall pain, a 62-year-old male undergoes a plain radiograph of the ribs. While no fractures are identified, the radiologist notes an incidental 14-mm, well-circumscribed, noncalcified nodular opacity in the peripheral right upper lobe. The patient has a 35-pack-year smoking history but quit 5 years ago. He reports no cough, hemoptysis, or unintentional weight loss. Vital signs are within normal limits, and pulmonary auscultation reveals clear breath sounds bilaterally. Attempts to locate prior imaging studies from other institutions are unsuccessful. Which of the following is the most appropriate next step in the diagnostic workup of this incidental finding?

A 55-year-old woman is brought to the emergency department by emergency medical services due to severe, worsening respiratory distress that began earlier today. Her medical history is significant for severe persistent asthma, and she was recently hospitalized for an exacerbation. On arrival, the patient is somnolent and difficult to arouse. She is using prominent accessory muscles of respiration and exhibits paradoxical abdominal movement. Vital signs are temperature 37.2°C (99.0°F), heart rate 138/min, respirations 32/min, blood pressure 155/92 mmHg, and oxygen saturation 81% despite receiving 15 L/min of oxygen via a non-rebreather mask. Pulmonary auscultation reveals a "silent chest" with markedly diminished breath sounds and no audible wheezing bilaterally. Intravenous access is established. Which of the following is the most appropriate immediate next step in the management of this patient?

A 71-year-old man presents to an urgent care clinic with sudden-onset, severe pain in his right foot that awakened him from sleep. The patient states the pain is so intense that he cannot tolerate a bedsheet touching his foot. His medical history includes ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, chronic kidney disease, and type 2 diabetes mellitus. His daily medications are sacubitril-valsartan, carvedilol, empagliflozin, and torsemide. Vital signs include a blood pressure of $108/65\text{ mm Hg}$, heart rate of $72/\text{min}$, and temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$). Physical examination reveals a visibly swollen, distinctly erythematous, warm, and exquisitely tender right first metatarsophalangeal joint. Laboratory studies show:

Leukocyte count: $11,200/\text{mm}^3$
Serum uric acid: $8.8\text{ mg/dL}$
Serum creatinine: $2.3\text{ mg/dL}$ (baseline $1.5\text{ mg/dL}$)

Which of the following is the most appropriate initial pharmacologic intervention for this patient's acute joint symptoms?

During morning rounds on the cardiology step-down unit, a physician assesses a $72$-year-old male who complains of excruciating pain in his right big toe that began overnight. The patient was hospitalized $72$ hours ago for volume overload requiring aggressive diuresis with intravenous furosemide. His respiratory status has since stabilized.

Physical examination of the right foot reveals prominent erythema, swelling, and exquisite tenderness localized to the first metatarsophalangeal joint. Arthrocentesis yields synovial fluid containing $35,000 \text{ leukocytes/mm}^3$ ($90\%$ neutrophils) and numerous negatively birefringent, needle-shaped crystals under polarized light microscopy.

His medical history is significant for ischemic cardiomyopathy (left ventricular ejection fraction $25\%$), chronic kidney disease (baseline creatinine $2.1 \text{ mg/dL}$), and a life-threatening peptic ulcer bleed $4$ months ago that required endoscopic clipping.

Today's vital signs are within normal limits. Laboratory studies show a current serum creatinine of $2.3 \text{ mg/dL}$.

Which of the following is the most appropriate targeted pharmacotherapy for this patient's acute joint pathology?

A 62-year-old man is evaluated in the hospital for a decreased platelet count. He was admitted 6 days ago for a massive pulmonary embolism and was initially treated with an intravenous unfractionated heparin infusion. He was transitioned to oral warfarin 2 days ago, but the heparin infusion was continued as a bridge. His platelet count on admission was $320,000/\text{mm}^3$. Today's complete blood count reveals a platelet count of $140,000/\text{mm}^3$. His hemoglobin and leukocyte counts are normal. He has no active bleeding, and physical examination shows no new petechiae, ecchymoses, or signs of recurrent deep vein thrombosis. A review of his peripheral blood smear shows normal red blood cell morphology and confirms the thrombocytopenia without platelet clumping. Which of the following is the most appropriate next step in laboratory evaluation?

A 45-year-old woman presents to the gastroenterology clinic for evaluation of a six-month history of chronic, non-bloody, watery diarrhea. She reports having 4 to 6 large-volume bowel movements daily, which frequently awaken her from sleep at night. She has experienced an unintentional 5-kg (11-lb) weight loss during this period. She denies abdominal pain, fever, or recent travel. Vital signs are within normal limits. Physical examination is unremarkable. A review of her records indicates that during a brief hospital admission two months ago, fasting for 24 hours did not significantly reduce her stool volume. The physician recognizes this presentation as a secretory diarrhea pattern and is expanding the medical history to determine the underlying etiology. Which of the following historical elements are the MOST critical to elicit as they represent classical causes of this specific pathophysiologic type of diarrhea? (Select all that apply)

Paramedics arrive at the trauma bay with a commercial roofer who plummeted two stories onto concrete. Initial assessment reveals profound bradycardia at 48/min, marked hypotension at 76/40 mm Hg, and shallow respirations at 8/min. Pulse oximetry reads 85% on room air. He is unresponsive to verbal stimuli. Gurgling sounds are audible with each breath, and pooled blood is visible in his posterior pharynx. His extremities are unusually warm and pink despite the severe hypotension. Arrange the following initial stabilization and diagnostic steps in the most appropriate chronological order of execution for this patient.

During a routine follow-up appointment, a $44$-year-old female patient reports experiencing profound muscle weakness and frequent nocturia over the past $3$ months. She has a $3$-year history of hypertension that remains poorly controlled despite daily adherence to a regimen of lisinopril and hydrochlorothiazide. Her current blood pressure is $165/102\text{ mmHg}$, and her heart rate is $78\text{/min}$. Physical examination demonstrates a normal body mass index, no striae or central adiposity, an absence of peripheral edema, and normal deep tendon reflexes.

A comprehensive metabolic panel reveals the following:

To further evaluate the refractory hypertension and electrolyte abnormalities, additional serologic testing is obtained:

Based on these laboratory findings, which of the following pathophysiologic mechanisms is the most accurate interpretation of this patient's condition?

An attending physician on the internal medicine teaching service is reviewing the diagnostic workup plans for four newly admitted patients with distinct systemic presentations. Match each patient's clinical vignette with the most appropriate targeted initial laboratory investigation.

A 42-year-old woman presents to the clinic with progressive fatigue, shortness of breath on exertion, and a chronic, nonproductive cough over the past three months. She has also experienced an unintentional 4-kg (8.8-lb) weight loss. Her past medical history is notable for mild asthma. She works as a software developer and recently acquired a pet parrot. Vital signs are temperature 37.0°C (98.6°F), blood pressure 122/78 mmHg, heart rate 74/min, and respiratory rate 16/min. Physical examination reveals bilateral fine crackles in the mid and upper lung fields. Chest radiography demonstrates bilateral hilar lymphadenopathy and reticulonodular opacities, predominantly in the upper lung zones. Laboratory studies show a serum calcium level of 11.4 mg/dL and a serum creatinine of 0.8 mg/dL. An electrocardiogram reveals first-degree atrioventricular block. Which of the following is the most likely diagnosis?

A 62-year-old man presents to the clinic with sudden-onset double vision that began this morning. He reports that the double vision resolves when he covers his right eye. Medical history is significant for type 2 diabetes mellitus for 15 years, hypertension, and hyperlipidemia. His medications include metformin, lisinopril, and atorvastatin. Vital signs are within normal limits. On physical examination, the right eye is deviated downward and outward at rest, and there is significant right-sided ptosis. The left eye has normal extraocular movements. Pupillary examination reveals that the right pupil is 3 mm and the left pupil is 3 mm; both react briskly to direct and consensual light. Visual acuity is 20/25 bilaterally. Based on the physical examination findings, which of the following is the most likely underlying mechanism for this patient's presentation?

A 45-year-old male is evaluated in the pulmonology clinic for progressive dyspnea on exertion and a chronic, nonproductive cough that has worsened over the last 6 months. He works as a sandblaster and ship fitter at a local commercial shipyard. He has never smoked and has no other notable medical history. Vital signs are within normal limits. Physical examination reveals normal breath sounds bilaterally without wheezes or crackles. High-resolution computed tomography (HRCT) of the chest reveals diffuse, small nodular opacities predominantly in the upper lobes, along with distinct "eggshell" calcification of the hilar lymph nodes.

Arrange the following interstitial lung diseases in order of pre-test probability for this patient, from highest probability (most likely) to lowest probability (least likely).

Paramedics rush a cyanotic, gasping male patient into the resuscitation bay after he collapsed in a local park. Bystanders reported the patient was swarmed by yellow jackets approximately 15 minutes prior. The patient's spouse, who arrives shortly after, provides a medication list indicating he takes carvedilol, sacubitril-valsartan, empagliflozin, and apixaban for a history of heart failure with reduced ejection fraction. Vital signs on the monitor display a blood pressure of 68/36 mmHg, a pulse of 115/min, and an oxygen saturation of 85% on room air. Examination shows profound periorbital and labial edema, audible stridor, widespread urticaria, and poor air entry bilaterally with faint wheezing. Establish the most appropriate chronological sequence of pharmacologic interventions to stabilize this patient.