All practice questions

During a neuroradiology case conference, residents are asked to correlate specific magnetic resonance imaging (MRI) patterns with their corresponding neurological etiologies. Based on current diagnostic guidelines, match each central nervous system disorder with its most characteristic MRI brain finding.

A 38-year-old female presents to the clinic complaining of severe, generalized muscle weakness that has progressively worsened over the past three days. She has a past medical history of Sjögren syndrome, for which she regularly uses artificial tears and saliva substitutes. She denies diarrhea, vomiting, or recent changes to her diet. Vital signs are within normal limits. Laboratory studies are obtained and reveal the following:

Urine studies show:

Which of the following mechanisms best explains this patient's laboratory findings?

A 72-year-old man is evaluated in the emergency department for severe, diffuse abdominal pain that began suddenly 3 hours ago. His medical history is significant for hypertension, type 2 diabetes mellitus, and paroxysmal atrial fibrillation, for which he has been noncompliant with his anticoagulant medication. Temperature is 37.8°C (100.0°F), blood pressure is 105/65 mmHg, pulse is 118/min and irregular, and respiratory rate is 22/min. Physical examination reveals a mildly distended abdomen with diffuse tenderness but no focal guarding or rebound tenderness. Bowel sounds are hypoactive. Laboratory studies show a leukocyte count of 18,500/mm³ and a serum lactate level of 5.2 mmol/L. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis reveals diminished enhancement of the small bowel wall, linear gas collections within the intestinal wall, and branching radiolucencies extending to the peripheral subcapsular regions of the liver. Based on the patient's presentation and imaging findings, which of the following is the most appropriate next step in management?

A 32-year-old man with no known medical history is brought to the emergency department by emergency medical services (EMS). His roommate found him unresponsive and experiencing generalized tonic-clonic movements. EMS reports that the continuous seizure activity began 25 minutes ago. Paramedics established peripheral intravenous access en route but did not administer any medications. Upon arrival, the patient remains unresponsive with ongoing rhythmic jerking of his extremities. His blood pressure is 145/88 mm Hg, heart rate is 132/min, and oxygen saturation is 94% on a non-rebreather mask. Fingerstick blood glucose is 102 mg/dL. The emergency physician initiates a protocolized escalation for status epilepticus. Assuming the patient's seizures remain completely refractory to each successive pharmacological intervention, arrange the following therapies in the correct chronological sequence of administration, progressing from initial emergent therapy to salvage therapy for super-refractory status epilepticus.

Match each of the following disorders of calcium and bone metabolism to its most characteristic pattern of laboratory findings.

A 64-year-old man is admitted to the general medical ward for a 3-day history of productive cough, high fevers, and right-sided pleuritic chest pain. His medical history is significant for coronary artery disease, hypertension, and highly symptomatic paroxysmal atrial fibrillation. His daily medications include dofetilide, apixaban, lisinopril, and atorvastatin. His temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, pulse is $78/\text{min}$, respiratory rate is $22/\text{min}$, and oxygen saturation is $92\%$ on room air. Physical examination reveals bronchial breath sounds and crackles in the right lower lung field. Laboratory studies show a leukocyte count of $14,500/\mu\text{L}$ with $82\%$ neutrophils. Serum electrolyte levels and renal function are within normal limits. An electrocardiogram demonstrates normal sinus rhythm with a corrected QT (QTc) interval of $475\text{ ms}$. Chest radiography confirms a right lower lobe consolidation. Which of the following is the most appropriate empiric pharmacologic regimen for this patient?

An on-call physician is summoned to the surgical step-down unit to evaluate an 81-year-old male who underwent a left total hip arthroplasty three days ago. The patient has been receiving intravenous hydromorphone for postoperative pain control. He complains of progressive abdominal bloating and cramping over the past 36 hours and reports no bowel movements or flatus since the surgery. His medical history is significant for chronic constipation, hypertension, and Parkinson disease. Vital signs demonstrate a heart rate of 105/min, blood pressure of 135/85 mm Hg, and temperature of 37.2°C (99.0°F). On physical examination, the abdomen is markedly distended and tympanic to percussion. There is mild, diffuse tenderness to deep palpation, but no guarding, rigidity, or rebound tenderness is appreciated. Laboratory results reveal a leukocyte count of 9,500/mm³. An anteroposterior supine abdominal radiograph demonstrates a massive, featureless, ahaustral loop of bowel resembling a bent inner tube. The apex of this dilated loop projects toward the right upper quadrant. There is a paucity of gas in the distal rectum, and no free intraperitoneal air is visualized.

Based on the interpretation of these radiographic findings and the clinical presentation, which of the following is the most appropriate initial step in management?

A 67-year-old man presents to the clinic with a 3-month history of progressively worsening fatigue, generalized weakness, and severe, aching mid-back pain. The pain does not radiate and is not relieved by over-the-counter analgesics. He has no history of trauma, weight loss, or constitutional symptoms. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $135/85 \text{ mmHg}$, pulse is $88/\text{min}$, and respiratory rate is $14/\text{min}$.

Physical examination reveals conjunctival pallor and point tenderness to percussion over the T10 and T11 spinous processes. Neurologic examination of the lower extremities shows $5/5$ motor strength, intact sensation to light touch and pinprick, and $2+$ bilateral patellar and Achilles reflexes.

Initial laboratory studies obtained yesterday reveal:

The physician suspects a plasma cell dyscrasia. Which of the following diagnostic investigations should be ordered concurrently as the most appropriate next steps in this patient's diagnostic workup? (Select exactly two)

A 26-year-old man comes to the clinic requesting screening for sexually transmitted infections. He reports a new male sexual partner 3 weeks ago and notes one episode of unprotected insertive and receptive anal intercourse. He feels well and has no fever, rash, sore throat, or lymphadenopathy. Vital signs are within normal limits. The physician plans to evaluate the patient for human immunodeficiency virus (HIV). Arrange the following diagnostic laboratory tests in the correct sequential order according to the standard HIV testing algorithm.

A 62-year-old man comes to the outpatient clinic for a follow-up evaluation. Over the past 4 months, he has experienced progressive fatigue, muscle weakness, and worsening constipation. He also reports an unintentional weight loss of 5 kg (11 lb) during this time. His medical history is significant for hypertension and a 35-pack-year smoking history, although he quit smoking 2 years ago. His only medication is hydrochlorothiazide. Vital signs are within normal limits. Physical examination reveals no palpable cervical, supraclavicular, or axillary lymphadenopathy. Cardiopulmonary and abdominal examinations are unremarkable.

Laboratory studies reveal the following:

A chest radiograph demonstrates bilateral hilar lymphadenopathy without focal pulmonary consolidations. Based on the clinical presentation and laboratory findings, which of the following is the most likely diagnosis?

A 42-year-old male construction worker is brought to the emergency department by paramedics after being extricated from beneath a collapsed concrete retaining wall, where he was trapped for approximately seven hours. Upon arrival, the patient is somnolent and weakly responsive to painful stimuli. His bilateral lower extremities are severely swollen, ecchymotic, and tense to palpation, with absent pedal pulses. Vital signs reveal a blood pressure of 82/48 mm Hg, a heart rate of 52/min, a respiratory rate of 22/min, and an oxygen saturation of 95% on supplemental oxygen. A stat 12-lead electrocardiogram demonstrates absent P waves, markedly widened QRS complexes, and tall, peaked T waves. Which of the following is the single most urgent initial step in the stabilization of this patient?

A $32$-year-old woman comes to the clinic for a preoperative evaluation prior to an elective laparoscopic cholecystectomy. She has a history of symptomatic gallstones but is otherwise healthy. The patient has never undergone surgery before and has no history of heavy menstrual bleeding, easy bruising, or frequent epistaxis. She does not take any prescription or over-the-counter medications. Her family history is unremarkable for any bleeding or clotting disorders. Physical examination shows normal vital signs and no petechiae, ecchymoses, or hepatosplenomegaly.

Routine preoperative laboratory tests show:

Which of the following is the most appropriate next step in laboratory evaluation?

Match each distinct abdominal or gastrointestinal physical examination finding with its corresponding pathophysiological mechanism.

A 48-year-old man presents to the emergency department reporting severe, constant epigastric pain that radiates to his back, which began 6 hours ago. The pain is associated with nausea and two episodes of non-bilious vomiting. He has no significant past medical history and takes no medications. He reports drinking 1 to 2 beers on occasional weekends. Vital signs show a temperature of 37.8°C (100.0°F), heart rate of 105/min, blood pressure of 135/85 mmHg, and respiratory rate of 18/min. Physical examination reveals diminished bowel sounds and marked epigastric tenderness to deep palpation, without guarding or rebound tenderness. Laboratory studies show:

Leukocyte count: 12,500/mm³
Serum lipase: 2,500 U/L
Aspartate aminotransferase (AST): 180 U/L
Alanine aminotransferase (ALT): 310 U/L
Alkaline phosphatase: 150 U/L
Total bilirubin: 1.8 mg/dL

Following initial fluid resuscitation and pain management, which of the following is the most appropriate next step in the diagnostic workup?

A 55-year-old woman presents to the outpatient clinic with a 6-month history of progressive, non-bloody diarrhea, abdominal bloating, and unintended weight loss. She describes her stools as voluminous and malodorous. Her past medical history is significant for type 1 diabetes mellitus and Hashimoto thyroiditis. Her current medications include insulin lispro, insulin glargine, and levothyroxine. Vital signs are within normal limits. Physical examination demonstrates mild, diffuse abdominal distension without guarding or rebound tenderness. Initial laboratory evaluation reveals a hemoglobin of 10.2 g/dL and a mean corpuscular volume of 74 fL. The physician suspects an underlying condition that explains both her gastrointestinal symptoms and laboratory abnormalities. Which of the following questions is most critical to ask during the history taking to further support the suspected diagnosis?

Emergency medical services transport a 29-year-old female to the resuscitation bay following an intentional pharmaceutical ingestion. Empty pill bottles for amitriptyline and sustained-release diltiazem were found beside her. On arrival, she is lethargic and responds only to painful stimuli. Vital signs include a temperature of 36.8°C (98.2°F), blood pressure of 78/40 mm Hg, heart rate of 52/min, and respiratory rate of 14/min. Physical examination is notable for dry mucous membranes, mydriasis, and delayed capillary refill. An electrocardiogram reveals sinus bradycardia with a PR interval of 240 ms, a QRS duration of 145 ms, and a QTc interval of 510 ms. Bedside capillary blood glucose is 142 mg/dL. Intravenous fluid resuscitation is commenced. Which of the following pharmacologic interventions are most appropriate to initiate next? (Select all that apply)

A 56-year-old woman is evaluated in the clinic for follow-up of major depressive disorder. Two months ago, she was started on sertraline. She reports that her mood has minimally improved, but she has developed new-onset progressive fatigue, frequent nausea, and mild muscle cramps over the past two weeks. Her medical history is also significant for partial complex seizures, which have been well controlled on levetiracetam for the past five years. Her blood pressure is $128/82 \text{ mmHg}$, pulse is $76/\text{min}$, and respirations are $14/\text{min}$. Physical examination reveals mild lethargy and sluggish deep tendon reflexes, but no focal neurologic deficits. Laboratory studies show:

A review of her records shows a normal basic metabolic panel three months ago. Sertraline is discontinued, and fluid restriction is initiated for the management of syndrome of inappropriate antidiuretic hormone (SIADH) secretion. The patient continues to experience severe depressive symptoms and requests an alternative treatment.

Which of the following is the most appropriate medication to treat this patient's depression?

A clinician is evaluating five adult patients who present with generalized fatigue and are found to have hemoglobin levels between $8.5$ and $10.2 \text{ g/dL}$. Match each of the following detailed laboratory profiles to the most likely underlying hematologic diagnosis.

A 32-year-old man presents to the clinic for a routine check-up required by his new employer. He feels well and has no fatigue, abdominal pain, bone pain, or changes in urination. He takes no medications. His family history is significant for his father being diagnosed with a "mild calcium problem" years ago, which never required surgical treatment. Vital signs are within normal limits, and physical examination is unremarkable.

Laboratory studies are obtained:

Which of the following best explains this patient's laboratory findings?

A medical student is rotating through the gastroenterology service and evaluates four patients with varying complaints of difficulty swallowing. Match each patient's clinical presentation with the most likely underlying etiology of their dysphagia.