All practice questions

A 64-year-old woman arrives at the emergency department with a 24-hour history of severe right-sided flank pain, intense chills, and acute confusion. Vital signs reveal a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure of 88/54 mmHg, and a heart rate of 118/min. Physical examination is notable for exquisite right costovertebral angle tenderness. Initial laboratory evaluation demonstrates a leukocyte count of $18,500/\text{mm}^3$ and a serum creatinine level of $1.9 \text{ mg/dL}$. A non-contrast CT scan of the abdomen and pelvis shows a 9-mm calculus in the proximal right ureter accompanied by severe hydronephrosis and perinephric fat stranding.

Arrange the following patient management and procedural interventions in the most appropriate chronological sequence for this patient.

A 26-year-old woman comes to the urgent care clinic due to a 4-day history of joint pain and a new rash. The pain initially involved her left elbow and right wrist but currently affects her right ankle, making it difficult to walk. She also reports intermittent subjective fevers over the same period. Her medical history is unremarkable, and she takes an oral contraceptive. She has been sexually active with a new male partner for the past two months. Her temperature is 38.2°C (100.8°F), blood pressure is 110/70 mm Hg, and pulse is 98/min. Physical examination reveals swelling, warmth, and marked tenderness along the dorsum of the right wrist and over the left Achilles tendon. There is no significant joint effusion in the knees or ankles. Auscultation of the heart reveals a grade 1/6 early systolic murmur at the left lower sternal border. Skin examination shows a few sparse, discrete necrotic pustules on an erythematous base located on the distal upper and lower extremities. Pelvic examination reveals no cervical motion tenderness or vaginal discharge. Which of the following is the most likely diagnosis?

Match each classic high-resolution computed tomography (HRCT) chest imaging finding with its most strongly associated clinical diagnosis.

A 67-year-old woman is brought to the emergency department from a skilled nursing facility due to a 2-day history of progressively worsening abdominal pain, distension, and obstipation. She has a medical history significant for Parkinson disease, chronic constipation, and severe osteoarthritis. Her current medications include carbidopa-levodopa, polyethylene glycol, and acetaminophen. Vital signs show a temperature of 37.6°C (99.7°F), blood pressure of 105/65 mmHg, heart rate of 115/min, and respiratory rate of 20/min. Physical examination reveals a markedly distended and tympanitic abdomen with diffuse tenderness. There is no rebound tenderness or guarding. Laboratory studies show a leukocyte count of 11,500/mm³ and normal serum electrolyte levels. An abdominal plain radiograph demonstrates a massively dilated, comma-shaped loop of bowel projecting from the right lower quadrant toward the left upper quadrant. A subsequent computed tomography scan of the abdomen shows a markedly distended cecum with mesenteric twisting and a transition point in the right colon. Which of the following is the most appropriate next step in management?

A $45$-year-old woman is evaluated in the intensive care unit for fever and hypotension. She was admitted $12$ days ago for induction chemotherapy for acute myeloid leukemia. Over the past $24$ hours, her temperature has spiked to $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), and her blood pressure has dropped to $85/50\text{ mmHg}$, remaining hypotensive despite a $2\text{ L}$ intravenous normal saline bolus. She has a central venous catheter in her right internal jugular vein. She currently complains of severe perianal pain. Physical examination reveals an indurated, exquisitely tender, and erythematous perianal region without fluctuance. Laboratory studies show an absolute neutrophil count of $100/\mu\text{L}$. The patient's medical record documents a history of severe anaphylaxis (laryngeal edema and hypotension) to amoxicillin. Blood and perianal tissue cultures are obtained.

Which of the following intravenous pharmacologic agents should be included in this patient's empiric antimicrobial regimen? (Select all that apply)

A 29-year-old G1P0 woman at 22 weeks gestation presents to the emergency department complaining of sudden-onset shortness of breath and right-sided chest pain that worsens with deep inspiration. The symptoms started 3 hours ago. She has no significant past medical history. Vital signs show a temperature of 37.1°C (98.8°F), heart rate of 118/min, blood pressure of 112/72 mmHg, respiratory rate of 24/min, and oxygen saturation of 94% on room air. Physical examination reveals clear lung fields bilaterally. Cardiac auscultation reveals tachycardia with a regular rhythm and no murmurs. Examination of the lower extremities demonstrates mild, asymmetric swelling of the left calf with localized tenderness. An electrocardiogram shows sinus tachycardia. A chest radiograph is unremarkable. Which of the following is the most appropriate next diagnostic test?

Emergency medical responders bring a 42-year-old man to the trauma center following a fall from a 6-meter (20-foot) scaffold. The patient is confused and visibly diaphoretic. Vital signs upon arrival include a heart rate of 138/min, blood pressure of 76/40 mm Hg, and respiratory rate of 28/min. Oxygen saturation is 91% on high-flow oxygen. Primary survey demonstrates tracheal deviation to the left, absent breath sounds on the right, and severe dullness to percussion over the right hemithorax. Bilateral large-bore intravenous access is established, and the institutional massive transfusion protocol is activated. A 36-French thoracostomy tube is promptly inserted into the right pleural space, which immediately drains 1,650 mL of frank blood. Despite the ongoing administration of blood products, the patient's blood pressure remains 82/45 mm Hg five minutes later. Which of the following is the most appropriate next step in the management of this patient?

A 54-year-old female teacher is brought to the emergency department by her spouse due to the sudden onset of a severe, diffuse headache that began roughly 8 hours ago. She describes it as unlike any headache she has ever experienced, reaching maximum intensity within seconds. The patient also reports significant nausea and sensitivity to light. Her past medical history is notable for well-controlled essential hypertension and hypothyroidism. Current medications include lisinopril and levothyroxine. On arrival, her temperature is 37.2°C (99.0°F), blood pressure is 162/94 mmHg, pulse is 92/min, and respiratory rate is 16/min. Physical examination demonstrates moderate resistance to passive neck flexion, but cranial nerves, motor strength, and sensory functions are fully intact. A non-contrast computed tomography (CT) scan of the head is obtained immediately and 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 72-year-old man presents to the emergency department with sudden, severe pain in his left lower leg that began 2 hours ago. He has a history of permanent atrial fibrillation but reports running out of his prescribed oral anticoagulant medication three weeks ago. On physical examination, his left foot and calf are pale and cool to the touch. The left femoral pulse is palpable, but the popliteal, dorsalis pedis, and posterior tibial pulses are absent to palpation and inaudible on continuous-wave Doppler ultrasound. Sensation is markedly decreased over the dorsum of the foot, and the patient is unable to move his toes. The right lower extremity is warm with strong distal pulses. Which of the following interventions are indicated for the immediate management of this patient? (Select all that apply)

A $62$-year-old woman is evaluated in the hospital for new-onset swelling and pain in her right lower extremity. She was admitted $6$ days ago for an acute pulmonary embolism and was immediately started on a continuous intravenous infusion of unfractionated heparin. Her respiratory status has significantly improved, but today she reports severe calf pain. Vital signs are within normal limits. Physical examination shows a right calf that is swollen, erythematous, and tender to palpation. Duplex ultrasonography confirms a new deep vein thrombosis in the right popliteal vein. Laboratory studies show a platelet count of $95,000/\mu L$, a significant decline from her admission platelet count of $260,000/\mu L$. Renal and hepatic function tests are within normal limits. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A $72$-year-old woman is brought to the emergency department from a skilled nursing facility due to severe lethargy and confusion over the past $12$ hours. Transport personnel report that she had a productive cough and foul-smelling urine for $3$ days prior to this acute decline. On arrival, she is unarousable to verbal stimuli but moans in response to painful stimuli. Vital signs include a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure of $76/40\text{ mm Hg}$, pulse of $128/\text{min}$, and respiratory rate of $28/\text{min}$. Oxygen saturation is $86\%$ on room air. Capillary refill time is $5$ seconds. Arrange the following initial stabilization and management steps in the most appropriate chronological sequence for this patient.

A 28-year-old woman is brought to the emergency department by her husband due to severe, diffuse abdominal pain that began 2 days ago. She also reports generalized weakness and a tingling sensation in her hands and feet. Her husband notes that she has been unusually anxious, restless, and confused since yesterday. Her medical history is significant for an uncomplicated urinary tract infection, for which she began taking trimethoprim-sulfamethoxazole 3 days ago. Her temperature is 37.1°C (98.8°F), blood pressure is 158/98 mm Hg, and pulse is 112/min. Physical examination shows a soft, non-distended abdomen with diffuse tenderness to palpation but no guarding or rebound. Bowel sounds are hypoactive. Neurologic examination reveals decreased sensation to pinprick in the bilateral hands and feet, as well as diminished deep tendon reflexes. Complete blood count, comprehensive metabolic panel, and serum lipase are within normal limits. A urine pregnancy test is negative. Which of the following is the most likely diagnosis?

A 45-year-old woman presents to the emergency department with a sudden-onset "thunderclap" headache, severe photophobia, and nuchal rigidity that began 12 hours ago. Her blood pressure is 155/90 mmHg, and her heart rate is 98/min. Neurologic examination reveals no focal deficits. Arrange the following diagnostic modalities and confirmatory protocols in the most appropriate sequential algorithm for the evaluation of this patient, starting with the initial diagnostic test.

A 45-year-old woman is evaluated in the surgical recovery unit two hours after an uncomplicated total thyroidectomy. The nursing staff urgently requests a physician assessment because the patient has become increasingly restless and reports severe neck tightness along with difficulty breathing. Physical examination reveals audible inspiratory stridor. Her surgical dressing is saturated with blood, and palpation reveals a tense, rapidly expanding swelling extending unilaterally beneath the incision line. Her vital signs are temperature 37.0°C (98.6°F), blood pressure 160/95 mm Hg, heart rate 118/min, and respiratory rate 28/min. Pulse oximetry demonstrates an oxygen saturation of 91% on room air. Which of the following is the most appropriate immediate next step in the management of this patient?

A 66-year-old man presents to the clinic for a follow-up evaluation of acute kidney injury. Over the past two months, he has experienced worsening fatigue and a dull, constant ache in his mid-to-lower back that is not relieved by rest. He has no significant past medical history and takes no medications. Vital signs are temperature 37.1°C (98.8°F), blood pressure 138/86 mmHg, pulse 82/min, and respirations 14/min. Physical examination reveals conjunctival pallor and mild tenderness to palpation over the lumbar spine. Laboratory studies are obtained and shown below:

Urinalysis
Color: Yellow
Specific gravity: 1.012
pH: 6.0
Protein: Trace
Blood: Negative
Glucose: Negative
Microscopy: 1-2 WBCs/hpf, 0-1 RBCs/hpf, occasional granular casts

A 24-hour urine collection is subsequently ordered and reveals a total protein excretion of 4.1 g/day. Based on these laboratory findings, which of the following is the most likely underlying mechanism of this patient's renal failure?

Seeking evaluation for a predictable pattern of chest discomfort, a 62-year-old male executive visits his primary care physician. Over the last six weeks, he has experienced a squeezing sensation in the center of his chest whenever he walks the two blocks from his commuter train to his office. The discomfort consistently subsides within five minutes of resting or sitting down. He has a history of type 2 diabetes mellitus, hypertension, and advanced osteoarthritis of both knees requiring the use of a mobility aid. Current medications include metformin, lisinopril, and as-needed acetaminophen. Vital signs show a blood pressure of 138/86 mmHg and a heart rate of 72/min. Cardiac auscultation reveals a regular rhythm with no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. A resting 12-lead electrocardiogram demonstrates sinus rhythm, left axis deviation, and a left bundle branch block. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's symptoms?

A 74-year-old woman presents to her primary care clinic to discuss progressive right knee pain that has been worsening over the past 6 months. She describes the pain as a deep, dull ache that worsens when climbing stairs and improves with rest. She experiences approximately 15 minutes of stiffness in the right knee upon waking in the morning. Her medical history includes hypertension, type 2 diabetes mellitus, stage 4 chronic kidney disease (baseline creatinine 2.4 mg/dL), and a remote history of a bleeding gastric ulcer that required endoscopic intervention. Her current medications are amlodipine, insulin glargine, and acetaminophen 1,000 mg three times daily. She reports that the acetaminophen no longer provides adequate pain relief. Vital signs are within normal limits. Physical examination reveals bony enlargement of the right knee with palpable crepitus during active range of motion. There is no significant warmth, erythema, or joint effusion. A recent radiograph of the right knee shows asymmetric joint space narrowing and subchondral sclerosis.

Which of the following is the most appropriate next step in the pharmacologic management of this patient's knee pain?

A 54-year-old man presents to the emergency department with a 3-hour history of sudden, severe, and diffuse abdominal pain. He has a history of chronic knee osteoarthritis and takes high-dose naproxen daily. He appears in acute distress and lies completely still on the stretcher. His temperature is 38.2°C (100.8°F), blood pressure is 102/64 mm Hg, pulse is 118/min, and respirations are 22/min. Abdominal examination reveals a rigid, board-like abdomen with diffuse guarding and rebound tenderness. Arrange the following steps in the most appropriate sequence for the management of this patient.

A 65-year-old man is evaluated in the surgical intensive care unit for acute right lower extremity pain and swelling. He underwent a coronary artery bypass graft 7 days ago. Since his surgery, he has been receiving subcutaneous unfractionated heparin for deep venous thrombosis (DVT) prophylaxis. Vital signs are stable. Physical examination reveals a swollen, erythematous, and tender right calf. Laboratory studies show a platelet count of $55,000/\mu L$, a significant decline from his baseline of $260,000/\mu L$ immediately post-operation. A compression Doppler ultrasound of the right lower extremity confirms a new occlusive DVT in the popliteal vein. A serotonin release assay is strongly positive. Arrange the following pharmacologic management steps in the correct chronological sequence to optimally treat this patient's acute thrombosis and safely transition him to long-term oral anticoagulation.

A 34-year-old woman is brought to the emergency department by paramedics after collapsing at a seafood restaurant. Her partner states she began complaining of an itchy throat and difficulty breathing shortly after eating a shrimp appetizer. Her past medical history is significant for asthma and a known shellfish allergy, but she did not have her epinephrine autoinjector with her. Upon arrival, she is lethargic and gasping for air. Physical examination reveals diffuse erythematous hives, marked periorbital edema, and audible inspiratory stridor. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 72/42 mm Hg, pulse of 142/min, respiratory rate of 32/min, and oxygen saturation of 86% on room air. Which of the following interventions should be ordered simultaneously as the immediate next steps in management? (Select all that apply)