All practice questions

Match each patient's clinical presentation of unilateral vision loss to the most appropriate diagnosis in the differential.

A male patient, aged $58$ years, with documented hepatic cirrhosis and portal hypertension, is evaluated in the emergency department following an episode of massive hematemesis. Upon arrival, he is obtunded, opening his eyes only to sternal rub, and actively vomiting bright red blood. His temperature is $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$), blood pressure is $74/42 \text{ mm Hg}$, heart rate is $128 \text{ /min}$, and respiratory rate is $24 \text{ /min}$. Pulse oximetry demonstrates an oxygen saturation of $92\%$ on ambient air. Physical examination reveals a pale, diaphoretic patient with cool extremities and a distended abdomen with shifting dullness.

Arrange the following initial management steps in the most appropriate chronological sequence for this patient.

A 63-year-old man with a 45-pack-year smoking history is evaluated in the pulmonary clinic. A routine preoperative chest radiograph reveals an incidental 14-mm noncalcified nodule in the peripheral right upper lobe. He has no hemoptysis, weight loss, or prior history of malignancy. To appropriately guide management, assume that the results of each subsequent diagnostic test continue to raise the suspicion for a primary lung malignancy without confirming a definitive diagnosis. Arrange the following radiological evaluations and image-guided procedures in the most appropriate chronological sequence for the diagnostic workup of this patient's solitary pulmonary nodule.

A 74-year-old man arrives at the emergency department reporting the sudden onset of severe, unremitting pain in his right leg that began 2 hours ago. His past medical history includes hypertension, hyperlipidemia, and paroxysmal atrial fibrillation. He discontinued his prescribed oral anticoagulant three weeks ago due to financial constraints. Vital signs include a temperature of 37.0°C (98.6°F), heart rate of 112/min with an irregularly irregular rhythm, and blood pressure of 145/85 mm Hg. Physical examination reveals that the right lower extremity is pale and cold from the mid-thigh down. A right femoral pulse is palpable, but the popliteal, dorsalis pedis, and posterior tibial pulses are absent on both palpation and continuous-wave Doppler ultrasound. The patient is unable to dorsiflex his right foot and reports profound numbness over the dorsum of the foot. The left lower extremity examination is unremarkable. Which of the following is the most appropriate next step in management?

A 68-year-old man presents to the clinic complaining of progressive fatigue, constipation, and lower back pain for the past 3 months. He has no prior medical history and takes no medications. Physical examination is notable for mucosal pallor and point tenderness over the L3 and L4 vertebrae.

Laboratory evaluation reveals the following:

Based on the synthesis of these laboratory findings, which of the following is the most likely diagnosis?

A 42-year-old woman is brought to the emergency department after experiencing the sudden onset of a severe, diffuse headache that she describes as the 'worst of my life,' accompanied by vomiting and photophobia. On physical examination, she is lethargic but arousable, with marked nuchal rigidity. Her vital signs show a blood pressure of 170/95 mmHg, heart rate of 98/min, and oxygen saturation of 99% on room air. The emergency physician suspects an aneurysmal subarachnoid hemorrhage (SAH) and initiates a diagnostic workup. Assuming positive or localizing findings at each diagnostic stage that necessitate further characterization, arrange the following imaging modalities in the most appropriate chronological sequence for the comprehensive diagnosis, etiological mapping, and subsequent intensive care monitoring of this patient.

A $42$-year-old woman comes to the clinic reporting excessive thirst and frequent urination for the past two months. She states she drinks up to $6\text{ L}$ of water daily and wakes up several times during the night to urinate. Her medical history is significant for bipolar I disorder, for which she has taken lithium for the past $8$ years. She has a history of severe manic episodes with psychotic features when she previously attempted to switch to alternative mood stabilizers. Vital signs are within normal limits.

Laboratory studies reveal:

A water deprivation test is performed. After $6$ hours of fluid restriction, her urine osmolality is $155\text{ mOsm/kg H}_2\text{O}$. Subcutaneous administration of desmopressin is given, and $2$ hours later, her urine osmolality is $160\text{ mOsm/kg H}_2\text{O}$. The patient's psychiatrist is consulted and strongly advises continuing the current lithium regimen due to the high risk of psychiatric decompensation.

Which of the following is the most appropriate pharmacologic intervention to manage this patient's polyuria?

Match each patient's clinical presentation of a severe or progressive headache with the most appropriate next diagnostic investigation in their workup algorithm.

During an annual comprehensive health screening, an asymptomatic $48$-year-old man is found to have elevated serum calcium levels. He has no history of nephrolithiasis, bone pain, abdominal discomfort, or psychiatric symptoms. He takes no medications, including over-the-counter supplements. His family history is notable for a brother who was told he had 'calcium problems' but never required surgical intervention. Vital signs and physical examination are unremarkable.

Subsequent laboratory investigations reveal the following:

Which of the following is the most likely diagnosis?

A 58-year-old man comes to the clinic for follow-up of a recently discovered adrenal mass. Two weeks ago, he presented to the emergency department with left lower quadrant abdominal pain and was diagnosed with uncomplicated diverticulitis via a noncontrast abdominal computed tomography (CT) scan. The CT scan incidentally revealed a 3.2-cm right adrenal nodule. A subsequent dedicated adrenal-protocol CT scan characterizes the mass as a benign-appearing adenoma. The patient's diverticulitis has completely resolved following a course of oral antibiotics. He feels well and reports no headaches, palpitations, or unexplained weight changes. Medical history is unremarkable, and he takes no medications. Blood pressure is 118/76 mmHg, pulse is 72/min, and BMI is 24 kg/m². Physical examination reveals no abdominal striae, supraclavicular fat pads, or proximal muscle weakness. Which of the following is the most appropriate next step in laboratory evaluation?

Emergency medical services transport a primigravid patient at 26 weeks gestation to the acute care bay following the sudden onset of right-sided pleuritic chest discomfort and shortness of breath. She has no significant past medical history, and her pregnancy has been uncomplicated to date. Vital signs show a heart rate of 115/min, respiratory rate of 24/min, blood pressure of 110/70 mmHg, and oxygen saturation of 93% on room air. Physical examination reveals clear lung fields bilaterally and a normal cardiac rhythm without murmurs. Her right leg is mildly edematous compared to the left, although she denies localized calf pain. An electrocardiogram demonstrates sinus tachycardia, and a portable chest radiograph is unremarkable. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 34-year-old woman comes to the clinic to discuss laboratory results obtained during a routine employer-mandated health screening. She feels completely well and reports no fatigue, polyuria, abdominal pain, or bone pain. She has no significant past medical history and takes no medications or dietary supplements. Family history is notable for mild, asymptomatic hypercalcemia in her father.

Vital signs and physical examination are within normal limits.

Initial screening labs showed a serum calcium level of $11.3$ mg/dL. Confirmatory laboratory studies are obtained today:

A 24-hour urine collection shows a total calcium excretion of $45$ mg/day. The calculated urine calcium-to-creatinine clearance ratio (UCCR) is $0.006$.

Which of the following is the most likely diagnosis?

A 34-year-old man presents to the emergency department with severe, acute-onset right upper quadrant abdominal pain and progressive abdominal swelling. Over the past six months, he has experienced recurrent episodes of profound fatigue and notes that his urine is occasionally dark red or brown, particularly when he wakes up in the morning. Two years ago, he was treated for a deep vein thrombosis in his left lower extremity following a long flight. Vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 135/85 mm Hg, heart rate of 105/min, and respiratory rate of 18/min. Physical examination reveals scleral icterus, tender hepatomegaly, and moderate ascites.

Laboratory studies:
Hemoglobin: 8.8 g/dL
Reticulocyte count: 7.5%
Leukocyte count: 3,200/mm³
Platelet count: 105,000/mm³
Total bilirubin: 4.1 mg/dL
Direct bilirubin: 0.6 mg/dL
Lactate dehydrogenase (LDH): 1,600 U/L
Haptoglobin: 8 mg/dL (Normal: 41-165 mg/dL)
Prothrombin time: 13 sec
Activated partial thromboplastin time: 30 sec

Abdominal duplex ultrasonography reveals absent flow in the hepatic veins. Which of the following is the most likely diagnosis?

A 68-year-old woman is evaluated in the preoperative clinic prior to an elective laparoscopic partial colectomy for recurrent diverticulitis. Her medical history is significant for a mechanical mitral valve replacement placed 4 years ago and a deep vein thrombosis 8 years ago. She currently takes warfarin and an angiotensin-converting enzyme (ACE) inhibitor. Her vital signs are within normal limits. Her international normalized ratio (INR) today is 2.8. The surgery is scheduled for 7 days from today. What are the mandatory perioperative management steps for this patient? (Select all that apply)

A $38$-year-old man with a history of HIV infection presents to the emergency department with a $2$-week history of progressively worsening headache, fever, and confusion. He has not taken antiretroviral therapy for the past year. Vital signs are temperature $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), pulse $105/\text{min}$, respirations $16/\text{min}$, and blood pressure $110/70\text{ mmHg}$. Physical examination shows lethargy, nuchal rigidity, and bilateral papilledema. A head CT scan without contrast reveals no focal lesions, mass effect, or hydrocephalus. Laboratory studies show a CD4 T-lymphocyte count of $45/\text{mm}^3$ and a serum sodium level of $131\text{ mEq/L}$. Lumbar puncture is performed. Cerebrospinal fluid (CSF) analysis shows an opening pressure of $360\text{ mm H}_2\text{O}$. CSF leukocyte count is $150/\text{mm}^3$ ($85\%$ lymphocytes), protein is $120\text{ mg/dL}$, and glucose is $30\text{ mg/dL}$. India ink preparation reveals encapsulated yeast cells. Which of the following pharmacologic interventions are indicated as part of this patient's immediate management? (Select all that apply)

A $62$-year-old male with a history of intravenous substance use is evaluated in the emergency department for severe, progressively worsening mid-back pain over the past week. Over the last $12$ hours, he has developed bilateral leg weakness and urinary retention. His temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $135/85\text{ mmHg}$, and heart rate is $108\text{/min}$. Neurological examination demonstrates $3/5$ strength in the bilateral lower extremities, diminished patellar reflexes, and absent sensation to pinprick in the perineal region. An emergent gadolinium-enhanced magnetic resonance imaging (MRI) of the spine is obtained. The radiologist's preliminary read describes a multi-loculated, T2-hyperintense, ring-enhancing fluid collection in the dorsal epidural space spanning T8 to T11, causing severe displacement and compression of the spinal cord. Based on the interpretation of these radiological findings, which of the following is the most appropriate next step in management?

A 68-year-old male is transported to the emergency department via ambulance with abrupt onset of excruciating, generalized abdominal pain that began 90 minutes prior to arrival. His past medical history is significant for a mechanical aortic valve replacement performed five years ago, for which he takes daily warfarin. He also has hypertension and diet-controlled type 2 diabetes. Upon arrival, he appears ashen and is diaphoretic. Temperature is 38.2°C (100.8°F), blood pressure is 82/48 mmHg, pulse is 134/min and regular, and respirations are 24/min. Abdominal examination demonstrates board-like rigidity, diffuse severe tenderness with guarding, and rebound tenderness across all four quadrants. A portable upright chest radiograph reveals a distinct crescent of radiolucency beneath the right hemidiaphragm. Point-of-care laboratory testing shows an international normalized ratio (INR) of 3.8 and a serum lactate of 5.2 mmol/L. Intravenous crystalloid resuscitation and broad-spectrum antibiotics are initiated. Which of the following interventions are mandatory immediate steps in this patient's management? (Select all that apply)

A 68-year-old man presents to the primary care clinic for follow-up after an emergency department visit for a syncopal episode earlier this week. He reports that he lost consciousness abruptly while attending an outdoor family gathering and recovered spontaneously within seconds. He denies any subsequent confusion, focal weakness, or urinary incontinence. He has a history of type 2 diabetes mellitus, essential hypertension, and a 40-pack-year smoking history. Current medications include metformin, amlodipine, and daily low-dose aspirin. His physical examination today is largely unremarkable, with a normal orthostatic blood pressure response and no focal neurological deficits. The physician is conducting a comprehensive medical history evaluation to differentiate the potential causes of his transient loss of consciousness. Which of the following specific historical elements, if elicited, would most strongly support a structural cardiac outflow obstruction as the primary etiology of his syncope?

Coworkers transport a 46-year-old farmhand to the emergency department after he collapsed in an orchard. They report that he was spraying crops earlier in the day when he suddenly developed severe shortness of breath, nausea, and vomiting. On arrival, the patient is agitated, diaphoretic, and in severe respiratory distress. Vital signs are temperature 36.8°C (98.2°F), pulse 42/min, blood pressure 86/54 mmHg, respirations 28/min, and oxygen saturation 84% on room air. Physical examination reveals profound salivation, lacrimation, and frothy sputum at the mouth. The pupils are 1 mm bilaterally. Pulmonary examination shows diffuse expiratory wheezing and coarse rhonchi in all lung fields. Neurologic examination is notable for generalized muscle fasciculations. Which of the following is the most urgent initial step in the stabilization of this patient?

During a local basketball tournament, a 24-year-old male athlete lands awkwardly on his left leg. He feels a distinct "pop" followed by immediate pain and rapid joint swelling. Two days later, he presents to an ambulatory clinic. He is unable to bear full weight due to a feeling that the knee will "give out." His medical history is unremarkable, and vital signs are within normal limits. Physical examination reveals a large left knee effusion. Active and passive flexion are limited to 45 degrees secondary to the swelling. The Lachman test demonstrates increased anterior translation of the tibia relative to the femur without a firm endpoint. Posterior drawer and varus/valgus stress testing are unremarkable. Which of the following is the most appropriate initial imaging study for this patient?