All practice questions

An otherwise healthy 34-year-old man presents to the emergency department with a 4-day history of progressive weakness in his legs. He reports numbness that started in his toes and has now ascended to his umbilicus, accompanied by a sensation of a "tight belt" around his mid-abdomen. Earlier today, he was unable to void urine for $12$ hours despite feeling a strong urge. Three weeks ago, he experienced a self-resolving episode of crampy abdominal pain and bloody diarrhea. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $128/82\text{ mmHg}$, and pulse is $88/\text{min}$. Physical examination reveals $3/5$ strength in the bilateral lower extremities and $5/5$ in the upper extremities. Deep tendon reflexes are $3+$ at the patellae and Achilles bilaterally. Sustained ankle clonus is present bilaterally, and plantar responses are upgoing. Pain and temperature sensation are absent below the level of the umbilicus. Sensation and reflexes in the upper extremities are normal. There is no spinal tenderness to percussion. Laboratory studies show a leukocyte count of $7,500/\mu\text{L}$, normal erythrocyte indices, and a serum vitamin $B_{12}$ level of $245\text{ pg/mL}$ (normal: $200$ to $900\text{ pg/mL}$). Which of the following is the most likely diagnosis?

A 45-year-old woman is hospitalized due to a 3-day history of high fever, dry cough, and right-sided pleuritic chest pain. She underwent a living-donor renal transplant 6 months ago for end-stage renal disease secondary to IgA nephropathy. Her current medications include tacrolimus, mycophenolate mofetil, and prednisone. Temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, pulse is $105/\text{min}$, and respirations are $20/\text{min}$. Oxygen saturation is $94\%$ on room air. Physical examination reveals crackles over the right upper lung field. Laboratory studies show:

A non-contrast CT scan of the chest demonstrates a 3-cm dense nodule with surrounding ground-glass opacity (halo sign) in the right upper lobe. Serum *Aspergillus* galactomannan antigen testing is markedly positive. Blood cultures are pending. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

Arrange the following diagnostic modalities in the most appropriate chronological sequence for the evaluation and staging of a 65-year-old man who presents to the outpatient clinic with a 3-week history of painless jaundice, acholic stools, weight loss, and a palpable, non-tender gallbladder. Initial laboratory results show a total bilirubin of 12.4 mg/dL and an alkaline phosphatase of 650 U/L.

A 72-year-old man is evaluated on the orthopedic ward for new-onset agitation and lower abdominal discomfort. He underwent an uncomplicated right total hip arthroplasty 8 hours ago under spinal anesthesia. His medical history includes hypertension, type 2 diabetes mellitus, and benign prostatic hyperplasia. Current medications include amlodipine, metformin, and as-needed oxycodone. Vital signs are temperature 37.1°C (98.8°F), blood pressure 158/92 mmHg, pulse 108/min, and respirations 18/min. Physical examination reveals a palpable, tender mass in the suprapubic region. A bedside bladder ultrasound demonstrates a fluid volume of 650 mL. A nurse attempts to place a standard 16-French urethral catheter but encounters firm resistance in the prostatic urethra and is unable to advance the catheter further. Which of the following is the most appropriate next step in the procedural management of this patient?

Emergency medical services bring a 19-year-old college student to the emergency department after he fell approximately 15 feet from a balcony. Paramedics report he was briefly conscious at the scene but rapidly became unresponsive during transport.

On arrival, his eyes are closed, he makes no vocal sounds, and he extends his upper extremities in response to painful stimuli.

Vital signs include a blood pressure of 190/100 mmHg, a heart rate of 48/min, a respiratory rate of 8/min with an irregular pattern, and an oxygen saturation of 89% despite a non-rebreather mask.

Primary survey reveals a boggy swelling over the right parietal area. Neurologic examination shows a right pupil measuring 7 mm and unreactive to light, while the left pupil is 3 mm and reactive.

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

A 29-year-old man is brought to the trauma resuscitation bay following a high-speed motor vehicle collision. Emergency medical services report a prolonged extrication time. Upon arrival, the patient is unresponsive. Vital signs show a pulse of 135/min, blood pressure of 82/50 mm Hg, and a respiratory rate of 35/min. Pulse oximetry indicates an oxygen saturation of 85% despite high-flow supplemental oxygen. Physical examination reveals significant maxillofacial trauma with active bleeding pooling in the oropharynx. The right hemithorax is hyperresonant to percussion with absent breath sounds. The abdomen is distended and rigid. Arrange the following management steps in the most appropriate sequential order according to standardized trauma resuscitation protocols.

A 65-year-old man is evaluated in the clinic after a routine preoperative chest radiograph for an elective inguinal hernia repair reveals a 15-mm solid nodule in the periphery of the right upper lung lobe. He has a 40-pack-year smoking history and quit 2 years ago. He reports no cough, hemoptysis, or weight loss. Vital signs are normal, and physical examination is unremarkable. Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's pulmonary nodule, from the immediate next step to the definitive diagnostic procedure.

A primary care physician evaluates an 82-year-old female resident of an assisted living facility who reports increasing difficulty walking to the dining hall without feeling breathless. Over the past six months, she has also experienced two transient episodes of profound lightheadedness when climbing a single flight of stairs. Her medical history includes well-controlled type 2 diabetes and essential hypertension. Blood pressure is 114/72 mmHg and pulse is 64/min. On cardiovascular examination, the point of maximal impulse is sustained and laterally displaced. Palpation of the carotid arteries reveals diminished and delayed upstrokes. Auscultation demonstrates a harsh, late-peaking systolic ejection murmur at the right second intercostal space that radiates to the bilateral cervical regions. Which of the following additional physical examination findings would most strongly indicate severe progression of this patient's underlying valvular condition?

An intensive care unit team is evaluating a 35-year-old previously healthy woman brought in by her husband due to sudden-onset confusion, lethargy, and severe right upper quadrant abdominal pain. Her husband reports she had been complaining of a "severe summer cold" with headaches, sinus pressure, and low-grade fevers for the past five days and had been managing her symptoms at home. She does not drink alcohol or use illicit drugs. On examination, the patient is oriented only to person. Scleral icterus is present.

Laboratory studies show:
Alanine aminotransferase (ALT): 6,800 U/L
Aspartate aminotransferase (AST): 7,500 U/L
Alkaline phosphatase: 140 U/L
Total bilirubin: 4.2 mg/dL
Prothrombin time: 28 seconds
International normalized ratio (INR): 2.6

Given the patient's presentation and marked laboratory abnormalities, obtaining collateral history regarding which of the following is the most critical next step to establish the etiology?

A 71-year-old male is evaluated in the hospital prior to discharge. He was admitted 3 days ago for acute decompensated heart failure presenting as sudden-onset pulmonary edema. He was successfully treated with intravenous furosemide and noninvasive positive pressure ventilation. He had a similar episode of flash pulmonary edema two months ago, despite having a normal left ventricular ejection fraction on a recent echocardiogram. Medical history includes hypertension, hyperlipidemia, and coronary artery disease. Two weeks prior to this admission, his primary care physician discontinued amlodipine and started valsartan due to poorly controlled blood pressure. Current medications include aspirin, atorvastatin, metoprolol, valsartan, and furosemide.

Vital signs today show a blood pressure of 178/96 mm Hg and a heart rate of 78/min. Physical examination reveals clear lungs bilaterally. Cardiac examination shows a regular rate and rhythm with an S4 gallop. Abdominal examination reveals a systolic-diastolic bruit heard in the periumbilical region.

Laboratory studies obtained this morning show:
Sodium: 139 mEq/L
Potassium: 4.8 mEq/L
Blood urea nitrogen: 44 mg/dL
Creatinine: 2.8 mg/dL (baseline was 1.2 mg/dL one month ago)

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

A 54-year-old man presents to the emergency department with a 4-day history of fever, pleuritic chest pain, and hemoptysis. He underwent an orthotopic heart transplant 8 months ago for nonischemic cardiomyopathy. His current daily medications include tacrolimus, mycophenolate mofetil, prednisone, and prophylactic valganciclovir. His temperature is 38.6°C (101.5°F), blood pressure is 118/74 mm Hg, pulse is 96/min, and respiratory rate is 20/min. Pulse oximetry shows 94% on room air. Physical examination reveals bronchial breath sounds and inspiratory crackles over the right upper lung field. High-resolution computed tomography of the chest demonstrates a dense right upper lobe consolidation surrounded by a ground-glass opacity (halo sign). Serum galactomannan assay is markedly elevated. Which of the following is the most appropriate pharmacologic management for this patient?

A 42-year-old woman, who immigrated to the United States from a resource-limited country 5 years ago, presents to the clinic with a 6-month history of progressively worsening exertional dyspnea, orthopnea, and occasional episodes of hemoptysis. She recalls experiencing a prolonged febrile illness with severe joint swelling during childhood that was never treated with antibiotics. Her vital signs show a blood pressure of 110/70 mmHg and a heart rate of 92/min with an irregularly irregular rhythm. Which of the following physical examination findings are most consistent with the most likely underlying structural cardiac disease in this patient? (Select two)

A $55$-year-old man with a history of alcohol-associated cirrhosis and esophageal varices is evaluated in the intensive care unit. He was admitted $3$ days ago for worsening ascites, confusion, and abdominal pain. Upon admission, diagnostic paracentesis revealed an absolute neutrophil count of $650 \text{ cells/mm}^3$. Intravenous ceftriaxone was initiated for spontaneous bacterial peritonitis. His home medications include oral lactulose, spironolactone, furosemide, and nadolol. Upon admission, his diuretics were held, but nadolol was continued for primary prophylaxis of variceal bleeding.

Over the past $48$ hours, he has received volume expansion with intravenous albumin ($1 \text{ g/kg/day}$). Despite these measures, his urine output has decreased to $300 \text{ mL/day}$ over the last $24$ hours.

Current vital signs:
Blood pressure: $86/52 \text{ mmHg}$
Heart rate: $105\text{/min}$
Temperature: $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$)

Microscopic urinalysis is normal with no red blood cells, casts, or protein. Renal ultrasound demonstrates normal kidneys without hydronephrosis.

Which of the following pharmacologic interventions are indicated at this time? (Select all that apply)

Match each clinical presentation of suspected pulmonary embolism with the most appropriate next step in diagnostic testing according to current guidelines.

A 68-year-old man presents to the clinic with progressive fatigue, tingling in both feet, and mild memory impairment over the past 6 months. He has a past medical history of primary hypothyroidism and vitiligo. Physical examination reveals a smooth, beefy-red tongue, pale conjunctivae, and diminished vibratory and position sensation in his bilateral lower extremities. Arrange the following diagnostic laboratory tests in the most appropriate sequential order to evaluate and establish the precise etiology of this patient's condition.

A 59-year-old man presents to the urgent care clinic with excruciating pain and swelling in his right great toe that began abruptly last night. He reports that the pain is so severe he cannot tolerate even the weight of a bedsheet on his foot. Medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, type 2 diabetes mellitus with a recent hemoglobin A1c of 9.2%, stage 4 chronic kidney disease with an estimated glomerular filtration rate of 22 mL/min/1.73 m², and a bleeding gastric ulcer that was treated endoscopically one month ago. Vital signs are temperature 37.1°C (98.8°F), blood pressure 118/75 mmHg, and heart rate 82/min. Examination reveals a markedly erythematous, swollen, and exquisitely tender right first metatarsophalangeal joint. Arthrocentesis yields synovial fluid with a leukocyte count of 45,000/mm³ and negatively birefringent, needle-shaped crystals. Which of the following is the most appropriate pharmacologic intervention for this patient's acute symptoms?

A $45$-year-old woman presents to the emergency department reporting the sudden onset of a severe, diffuse headache that began $18$ hours ago. She describes it as the "worst headache of my life." The headache was accompanied by two episodes of vomiting and sensitivity to light. Her past medical history is significant for hypertension and tobacco use. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse is $92$/min, blood pressure is $168/95$ mmHg, and respirations are $16$/min. On physical examination, the patient appears uncomfortable and prefers to keep the room lights off. Neurologic examination shows intact cranial nerves, $5/5$ motor strength in all extremities, and normal deep tendon reflexes. Neck flexion produces mild discomfort. A non-contrast computed tomography (CT) scan of the head reveals no evidence of intracranial hemorrhage, mass effect, or midline shift. Which of the following is the most appropriate next step in the diagnostic workup?

A $65$-year-old man is brought to the emergency department by his daughter due to three days of progressively worsening lower back pain and new-onset difficulty walking. He reports that the pain began abruptly after he attempted to lift a heavy piece of furniture. This morning, he developed perineal numbness and has been unable to urinate for the past $12$ hours despite feeling a strong urge. His medical history includes type 2 diabetes mellitus, hypertension, and sick sinus syndrome managed with a permanent dual-chamber cardiac pacemaker (implanted $14$ years ago; documentation confirms the device is strictly non-MRI compatible). His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $145/90\text{ mmHg}$, heart rate is $78/\text{min}$, and respiratory rate is $16/\text{min}$. Physical examination reveals exquisite tenderness to palpation over the lower lumbar spine. Neurologic examination demonstrates $3/5$ strength in bilateral lower extremities, decreased sensation to pinprick in the perineal and perianal region (saddle anesthesia), and absent Achilles reflexes bilaterally. Digital rectal examination reveals significantly decreased anal sphincter tone. Bedside bladder ultrasonography shows a post-void residual volume of $600\text{ mL}$. Which of the following is the most appropriate next step in diagnostic imaging?

A 38-year-old female patient is evaluated in the outpatient clinic for an 8-month history of progressive weight gain, generalized fatigue, and easy bruising. She has also noted the recent onset of facial hair growth and irregular menstrual cycles. She has no significant past medical history and takes no medications. Her blood pressure is $155/95 \text{ mmHg}$, and her body mass index is $34 \text{ kg/m}^2$. Physical examination demonstrates facial plethora, a prominent dorsocervical fat pad, and multiple violaceous striae across the abdomen. Proximal muscle weakness is evident in the bilateral lower extremities. Which of the following is the most appropriate next step in laboratory evaluation?

A 28-year-old man is brought to the emergency department via ambulance after being the unrestrained driver in a high-speed motor vehicle collision. On arrival, he is confused and diaphoretic. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), pulse is $132/\text{min}$, respirations are $22/\text{min}$, and blood pressure is $82/50\text{ mmHg}$. Oxygen saturation is 96% on a non-rebreather mask. The airway is patent, and breath sounds are equal bilaterally. Intravenous access is established, and volume resuscitation is initiated. A portable chest radiograph reveals no abnormalities, and a pelvic radiograph shows no fractures. A Focused Assessment with Sonography for Trauma (FAST) examination demonstrates a distinct anechoic strip between the right kidney and the liver, as well as an anechoic fluid collection in the rectovesical pouch. Based on the interpretation of these imaging findings and the patient's clinical status, which of the following is the most appropriate next step in management?