All practice questions

A 68-year-old woman is evaluated in the clinic for new-onset, severe right-sided headaches, scalp tenderness, and pain in her jaw when chewing over the past two weeks. Laboratory studies show an erythrocyte sedimentation rate of 85 mm/h. She is immediately started on high-dose oral prednisone. Four days later, a biopsy of the right temporal artery is performed.

The pathologist's report describes the following findings:
- Marked intimal hyperplasia causing luminal narrowing
- A transmural mixed inflammatory infiltrate composed primarily of lymphocytes and macrophages
- Extensive fragmentation of the internal elastic lamina
- No multinucleated giant cells are identified across multiple serial sections

Based on these histopathologic findings, which of the following is the most accurate diagnostic interpretation?

A 55-year-old man with a 30-pack-year smoking history undergoes a routine preoperative chest radiograph before an elective inguinal hernia repair. The radiograph reveals an incidental 1.4-cm solitary pulmonary nodule in the right upper lobe. He recently moved to the area and has no previous medical records immediately available at this facility. The patient is currently asymptomatic and his physical examination is unremarkable. Arrange the following diagnostic steps in the most appropriate sequence for evaluating this patient's solitary pulmonary nodule, proceeding from the immediate next step to the final definitive diagnostic procedure.

A 28-year-old man is brought to the emergency department via ambulance after a high-speed motor vehicle collision. He is agitated and in severe respiratory distress. Vital signs are heart rate 135/min, blood pressure 75/40 mm Hg, and respiratory rate 32/min. Oxygen saturation is 88% on a non-rebreather mask. Physical examination reveals distended neck veins, absent breath sounds over the right hemithorax, and tracheal deviation to the left. Which of the following is the most appropriate next step in management?

Paramedics have transported a $58$-year-old female to the resuscitation bay due to rapidly worsening shortness of breath and extreme fatigue over the last $24$ hours. Her past medical history is significant for metastatic non-small cell lung cancer currently treated with palliative immunotherapy.

Upon arrival, the patient appears ashen and lethargic. Initial vital signs reveal a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $72/40$ mm Hg, heart rate of $128$/min, and respiratory rate of $32$/min. Oxygen saturation is $88\%$ on a non-rebreather mask.

Cardiac auscultation reveals muffled and distant heart sounds. There is marked distention of the external jugular veins bilaterally while sitting at a $45$-degree angle. Lung fields are clear to auscultation. A bedside assessment demonstrates that her systolic blood pressure decreases by $25$ mm Hg during inspiration.

A point-of-care ultrasound is performed, which shows a large anechoic space surrounding the myocardium with dynamic inward collapse of the right ventricular free wall during diastole.

As the clinical team continues the assessment, the patient suddenly stops responding to verbal and painful stimuli, and her respiratory effort becomes shallow and irregular.

Which of the following interventions represents the single most appropriate immediate next step for this patient's stabilization?

A 67-year-old man presents to the urgent care clinic with a 4-day history of high fever, chills, and a worsening productive cough with yellow-green sputum. He also reports right-sided pleuritic chest pain that worsens with deep inspiration. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of 35%, paroxysmal atrial fibrillation, and major depressive disorder. Current medications include sacubitril-valsartan, dapagliflozin, dofetilide, rivaroxaban, and escitalopram. Vital signs show a temperature of 38.4°C (101.1°F), blood pressure of 122/78 mmHg, pulse of 78/min, and respiratory rate of 20/min. Oxygen saturation is 95% on room air. Physical examination reveals bronchial breath sounds, crackles, and egophony over the right lower lung field. An electrocardiogram shows normal sinus rhythm with a heart rate of 76/min and a QTc interval of 520 ms. A chest radiograph demonstrates a right lower lobe consolidation. Which of the following is the most appropriate empiric antimicrobial regimen for this patient?

A 56-year-old man presents to the clinic with an 8-month history of chronic, non-bloody diarrhea, a 12-kg (26-lb) weight loss, and migratory pain in his large joints. His wife notes that over the past two months, he has developed mild memory deficits and unusual, involuntary rhythmic eye movements synchronized with chewing. Physical examination reveals generalized lymphadenopathy and a low-grade fever. Laboratory testing demonstrates a hemoglobin of 9.8 g/dL with a mean corpuscular volume of 92 fL, and a serum albumin of 2.6 g/dL. Upper gastrointestinal endoscopy shows thickened, pale, and edematous duodenal folds. A duodenal mucosal biopsy is submitted for histopathologic evaluation to establish the diagnosis.

Which of the following histopathologic and staining findings are most characteristic of the expected underlying etiology in this patient? (Select all that apply)

A paramedic team brings a 42-year-old construction worker to the emergency department 12 hours after he suddenly clutched his head and collapsed to his knees at a job site. He reports that he was struck by an explosive, agonizing headache while lifting a heavy steel beam. He rates the pain as a 10 out of 10 and states it is unlike anything he has ever felt. The severe pain has persisted since onset. His vital signs show a blood pressure of 165/95 mm Hg, a pulse of 92/min, and a respiratory rate of 16/min. Neurologic examination reveals no focal motor or sensory deficits, but he experiences mild discomfort during neck flexion. An initial non-contrast computed tomography scan of the head is interpreted as normal by the attending radiologist. Which of the following is the most appropriate next step in the diagnostic workup?

A 45-year-old female is evaluated during a gastroenterology consultation for severe, refractory epigastric burning pain and voluminous, watery diarrhea that has persisted for the past eight months. She reports waking up multiple times at night due to the abdominal pain. She has been adherent to a twice-daily, high-dose proton pump inhibitor regimen for the past six months with minimal symptom relief.

An upper gastrointestinal endoscopy performed two days ago revealed prominent, hypertrophic gastric folds and multiple 1- to 2-cm deep ulcerations extending from the gastric antrum into the distal duodenum and proximal jejunum. She has no significant past medical history and takes no other medications.

Following specific instructions, the patient discontinued her proton pump inhibitor two weeks prior to laboratory evaluation, substituting it with a histamine-2 receptor antagonist that was strictly held for 48 hours before testing.

Laboratory results are as follows:

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

A 78-year-old woman with metastatic breast cancer to the bones and liver, complicated by malignant biliary obstruction, is brought to the emergency department for severe, generalized pain and worsening shortness of breath over the past 24 hours. She is lethargic, intermittently groaning, and oriented only to person. Vital signs are temperature 37.1 C (98.8 F), blood pressure 90/60 mm Hg, pulse 115/min, and respiratory rate 28/min. Oxygen saturation is 86% on room air. Laboratory studies show a serum creatinine of 3.8 mg/dL (baseline 1.1 mg/dL) and total bilirubin of 6.2 mg/dL.

No written advance directive is on file in the hospital system. Her husband of 50 years is at the bedside; he is distraught and insists the team "do everything, including a breathing machine, to keep her alive." The patient's adult daughter, who lives out of state, is contacted on the phone. The daughter provides a legally executed Durable Power of Attorney for Healthcare (DPOA-HC) document signed by the patient two years ago naming the daughter as the sole healthcare agent. The daughter firmly states that her mother recently expressed a strong desire to avoid mechanical ventilation and wishes only for interventions that prioritize comfort.

The patient is in visible respiratory distress, with accessory muscle use and severe grimacing when repositioned. Which of the following is the most appropriate next step in management?

A 28-year-old man comes to the clinic for a routine follow-up visit for generalized anxiety disorder. He has been a patient of the physician for two years. His symptoms are currently well-controlled with therapy and medication. At the end of the visit, the patient expresses romantic interest in the physician and asks if she would like to go out for dinner this weekend. Which of the following is the most appropriate response by the physician?

A 45-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He is awake, alert, and fully oriented to person, place, time, and situation. His blood pressure is 85/50 mm Hg and his heart rate is 120/min. Laboratory studies show a hemoglobin level of 6.2 g/dL. The physician explains that the patient has life-threatening acute blood loss and that a blood transfusion is immediately necessary to prevent death. The patient demonstrates a clear understanding of his condition, the proposed treatment, and the severe risks of refusing, including death. However, he steadfastly refuses the blood transfusion, stating that it violates his religious beliefs as a Jehovah's Witness. His wife, who is present at the bedside, is distraught and begs the physician to administer the blood to save her husband's life. Which of the following is the most appropriate next step in management?

A 78-year-old woman is evaluated in the clinic for a routine follow-up. She is accompanied by her 45-year-old daughter, who recently moved into the patient's home to serve as her primary caregiver. The patient's past medical history includes hypertension and mild osteoarthritis. She is cognitively intact and fully capable of making her own medical decisions. During the physical examination, while the daughter is out of the room, the physician observes multiple circular burn marks on the patient's upper back. When gently questioned about the injuries, the patient begins to cry and admits that her daughter burned her with a cigarette to "punish" her for occasional urinary incontinence. The patient adamantly refuses any intervention, stating, "I have full capacity and I know my rights. What I tell you is confidential. If you report this, she will leave me, and I will be forced into a nursing home. I explicitly forbid you from telling anyone." Which of the following is the most appropriate next step?

A 68-year-old man presents to the clinic with a 4-week history of generalized pruritus, darkening of his urine, and pale-colored stools. Over the past three months, he has unintentionally lost 6 kg (13 lb). He reports no abdominal pain, nausea, or vomiting. His past medical history is significant for hypertension and type 2 diabetes mellitus, which was newly diagnosed 6 months ago. He has a 40-pack-year smoking history. Vital signs are within normal limits. Physical examination reveals scleral icterus, excoriations on his extremities, and a palpable, non-tender mass in the right upper quadrant.

Laboratory studies show:
Total bilirubin: 11.2 mg/dL
Direct bilirubin: 8.8 mg/dL
Alkaline phosphatase: 580 U/L
Aspartate aminotransferase (AST): 85 U/L
Alanine aminotransferase (ALT): 92 U/L
Lipase: 45 U/L

An ultrasound of the right upper quadrant demonstrates marked intrahepatic and extrahepatic biliary dilation. The common bile duct measures 14 mm in diameter. The gallbladder is distended and thin-walled, with no echogenic shadowing to suggest cholelithiasis. The distal common bile duct and the pancreas are obscured by overlying bowel gas.

Which of the following is the most appropriate next step in the diagnostic workup?

A $74$-year-old woman is brought to the emergency department from a long-term care facility due to worsening lethargy and confusion over the past $24$ hours. Staff members report that her urine has been noticeably dark and foul-smelling. Her past medical history includes type 2 diabetes mellitus, essential hypertension, and advanced Alzheimer dementia. Upon physical examination, she is minimally responsive to painful stimuli but her airway remains patent. Her skin is warm, flushed, and dry. Vital signs show a temperature of $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$), blood pressure of $76/40\text{ mm Hg}$, heart rate of $122/\text{min}$, and respiratory rate of $24/\text{min}$. Oxygen saturation is $96\%$ on room air. Her capillary refill time is $4\text{ seconds}$. Which of the following are the most appropriate simultaneous initial steps in the management of this patient? (Select 2 answers)

A 54-year-old man with a documented severe anaphylactic allergy to penicillin is admitted to the hospital for acute diverticulitis. The admitting physician orders intravenous piperacillin-tazobactam. The electronic health record (EHR) triggers a high-severity allergy alert. Experiencing alert fatigue from numerous prior false-positive warnings, the physician clicks "override," typing "patient tolerates" without further chart review. The central pharmacist, handling a surge of intensive care orders, verifies the order without investigating the override rationale. The floor nurse, assuming the medication was cleared by both the physician and pharmacist, administers the infusion. The patient quickly develops anaphylactic shock, requires intubation, and is transferred to the medical intensive care unit. The hospital's risk management team convenes a multidisciplinary panel to review this sentinel event. Which of the following frameworks and corresponding system-level interventions is most appropriate for this panel to utilize to analyze this event and prevent recurrence?

A 34-year-old physician receives a "friend request" on a personal social media account from a 28-year-old patient who was recently evaluated in the clinic for an acute asthma exacerbation. Shortly after, the patient sends a direct message on the same personal platform describing a new, mildly painful skin rash and attaches a photograph of the lesion, asking for treatment advice. Which of the following are appropriate actions for the physician to take? (Select all that apply)

A 29-year-old woman is seen for a routine follow-up appointment regarding her major depressive disorder. During the consultation, she becomes tearful and confides that another physician within the same healthcare network—her gastroenterologist—has been sending her inappropriate, late-night text messages. She presents several messages on her phone that are explicitly romantic and sexual in nature. The patient states, "He is an excellent doctor and I do not want him to lose his license over this. I just needed to tell someone, but please keep this strictly between us." Which of the following actions MUST the physician take in this scenario? (Select all that apply)

A 34-year-old man presents to the neurology clinic to discuss the results of a recent predictive genetic test. His father was recently diagnosed with Huntington disease, prompting the patient to seek testing. The results confirm an expanded CAG trinucleotide repeat in the HTT gene, indicating he will eventually develop the disease. The patient is currently asymptomatic. He is married and has a 4-year-old son. He also has a 31-year-old biological sister who recently got married and is actively trying to conceive her first child. During the consultation, the patient becomes visibly distressed and states, 'I cannot let my wife or my sister know about this. It would ruin my marriage, and my sister would never speak to me again.' He explicitly forbids the physician from sharing his medical records or test results with anyone. Which of the following approaches by the physician are legally and ethically appropriate? (Select all that apply)

A 78-year-old man with advanced Parkinson disease and severe oropharyngeal dysphagia is evaluated during a home hospice visit. Over the past 24 hours, his level of consciousness has declined, and he is now unresponsive to verbal and tactile stimuli. His respiratory pattern is irregular, and each breath is accompanied by a loud, gurgling noise during both inspiration and expiration. The patient has a medical history significant for angle-closure glaucoma and benign prostatic hyperplasia complicated by recurrent urinary retention. His wife, who is his designated health care proxy, is severely distressed by his breathing sounds and tearfully asks, "He sounds like he is drowning; please do something to clear his chest!" Current medications include a continuous subcutaneous infusion of morphine, and carbidopa-levodopa administered via a gastrostomy tube. Vital signs reveal a pulse of 110/min, respirations of 26/min, and blood pressure of 90/50 mm Hg. Which of the following is the most appropriate next step in management?

A root cause analysis committee is reviewing several adverse events and near misses. To identify targeted mitigation strategies, each event must be correctly mapped to its underlying cognitive or systemic failure mode. Correlate the following event scenarios with their most precise classification in the human factors and medical error taxonomy.