All practice questions

Emergency medical services bring a 72-year-old woman to the acute care bay because she suddenly developed right-sided weakness, right facial droop, and severe expressive aphasia exactly 45 minutes prior to arrival. Her current blood pressure is 175/95 mmHg, and her heart rate is 92/min with an irregularly irregular rhythm. Medical records indicate a history of hypertension and atrial fibrillation, for which she recently stopped taking her anticoagulant medication. The clinical presentation is highly suspicious for an acute ischemic stroke. Which of the following are the most critical initial diagnostic tests that should be ordered immediately to determine her eligibility for acute pharmacological reperfusion therapy? (Select all that apply)

A 29-year-old woman, gravida 2, para 1, at 26 weeks gestation, comes to the emergency department due to sudden-onset shortness of breath and sharp, right-sided chest pain that worsens with deep inspiration. The symptoms began 2 hours ago. She also reports progressive swelling and discomfort in her left leg over the past 3 days. Her pregnancy has been uncomplicated, and she has no significant past medical history. She takes prenatal vitamins. Her temperature is 37.1 C (98.8 F), blood pressure is 112/70 mm Hg, pulse is 118/min, and respirations are 24/min. Pulse oximetry shows 94% on room air. Examination reveals clear lungs bilaterally. The cardiovascular examination is notable for tachycardia without murmurs. The left calf is visibly swollen, erythematous, and tender to palpation, with a circumference 4 cm greater than the right calf. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A hospital pathology department receives multiple percutaneous renal biopsy samples from the nephrology service over a single week. Match each distinct histopathological and immunofluorescence description to its definitive clinicopathologic diagnosis.

A $52$-year-old woman is brought to the emergency department by her husband due to the sudden onset of an excruciating headache that began $8\text{ hours}$ ago. She describes it as the "worst headache of my life" and reports one episode of vomiting and extreme sensitivity to room lights. Her medical history is significant for a mechanical mitral valve replacement performed $3\text{ years}$ ago for severe rheumatic mitral stenosis. Her daily medications include warfarin and metoprolol.

On presentation, her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $168/94\text{ mm Hg}$, pulse is $88/\text{min}$, and respiratory rate is $16/\text{min}$. Neurologic examination reveals a fully alert and oriented patient with intact cranial nerves, normal motor strength, and normal sensory function. Mild nuchal rigidity is present.

Laboratory studies show an international normalized ratio (INR) of $3.2$.

A non-contrast computed tomography (CT) scan of the head is performed and reveals no acute intracranial hemorrhage, mass effect, or midline shift.

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

A 54-year-old woman is evaluated in the ambulatory clinic for a palpable mass in her anterior neck, which she noticed two weeks ago while applying lotion. She denies dysphagia, hoarseness, palpitations, weight changes, or heat intolerance. Her medical history is unremarkable, and she takes no medications. Vital signs are within normal limits. Physical examination reveals a firm, non-tender, mobile $2.0 \text{ cm}$ nodule in the left thyroid lobe. No cervical lymphadenopathy is present. Laboratory studies show a serum thyroid-stimulating hormone (TSH) level of $2.4 \text{ mIU/L}$ (normal: $0.4 - 4.0 \text{ mIU/L}$). A dedicated thyroid ultrasound demonstrates a $2.1 \text{ cm}$ solid, markedly hypoechoic nodule in the left lower pole. The nodule has irregular, microlobulated margins and contains internal punctate echogenic foci. Based on these imaging results, which of the following is the most appropriate next step in management?

During a routine morning round on the telemetry unit, a hospitalized patient suddenly loses consciousness, and the central monitor instantly displays coarse ventricular fibrillation. No carotid pulse is palpable. Arrange the following emergency interventions in the correct chronological sequence according to standard Advanced Cardiac Life Support (ACLS) protocols for this specific presentation.

Match each patient's clinical presentation with the most appropriate next step in diagnostic imaging.

Match each patient's clinical presentation and initial coagulation laboratory findings with the most appropriate next step in diagnostic test sequencing.

For each of the following patient scenarios, select the most appropriate initial diagnostic investigation from the available choices.

Presenting to the emergency department is a 29-year-old pregnant patient at 27 weeks of gestation, complaining of acute-onset dyspnea and sharp, left-sided chest pain exacerbated by deep breathing. Her current pregnancy has been unremarkable, and she takes only prenatal vitamins. On arrival, her temperature is 37.2°C (99.0°F), blood pressure is 114/74 mm Hg, heart rate is 118/min, and respiratory rate is 24/min. Pulse oximetry indicates an oxygen saturation of 94% on room air. The patient appears acutely anxious. Auscultation of the lungs reveals diminished breath sounds at the left base. Cardiac auscultation shows tachycardia but no murmurs, rubs, or gallops. Examination of the lower extremities reveals no edema, erythema, or tenderness. An electrocardiogram shows sinus tachycardia. Bilateral lower extremity compression venous ultrasonography is negative for deep vein thrombosis. A portable chest radiograph demonstrates a small left-sided pleural effusion and atelectasis in the left lower lobe. Which of the following is the most appropriate next step in diagnostic imaging for this patient?

A 68-year-old man is brought to the emergency department by emergency medical services due to sudden-onset, severe shortness of breath. He has a history of ischemic cardiomyopathy with a known left ventricular ejection fraction of $25\%$. Upon arrival, the patient is lethargic, diaphoretic, and using accessory muscles of respiration. His blood pressure is $72/48$ mm Hg, heart rate is $122$/min, respiratory rate is $34$/min, and oxygen saturation is $82\%$ on room air. Physical examination reveals cool, mottled extremities and prominent jugular venous distention. Auscultation of the lungs demonstrates coarse crackles in all lung fields. Which of the following is the most appropriate initial step in the stabilization of this patient?

A 32-year-old rock climber is brought to the emergency department by paramedics after an estimated 30-foot fall. He arrives immobilized on a backboard with a rigid cervical collar in place. He is agitated, tachycardic, and has an obvious deformity of his right femur. Arrange the following steps of his initial trauma resuscitation in the correct chronological order according to standard Advanced Trauma Life Support (ATLS) primary survey principles.

Match each patient's clinical presentation to the single most appropriate initial or alternative imaging modality, taking into account patient-specific risk factors and evidence-based guidelines.

A 24-year-old female graduate student schedules an appointment at the university health clinic after noticing a lump in her right breast while showering. She reports that the lump has been present for approximately six weeks and has not fluctuated in size or tenderness with her menstrual cycles. Her medical history is unremarkable, and she takes no medications other than a combined oral contraceptive pill. Her family history is negative for breast or ovarian malignancies. Vital signs are within normal limits. On physical examination, there is a 2.5-cm, firm, highly mobile, non-tender, and well-circumscribed mass in the upper outer quadrant of the right breast. There is no overlying skin dimpling, nipple retraction, or palpable axillary lymphadenopathy. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 42-year-old woman is brought to the emergency department after experiencing a sudden, excruciating headache, which she describes as the 'worst of her life.' The headache started 4 hours ago and is accompanied by severe nausea, vomiting, and photophobia. Vital signs show a blood pressure of 165/95 mm Hg, a heart rate of 98/min, and a temperature of 37.2°C (99.0°F). Neurologic examination reveals neck stiffness but no focal motor or sensory deficits. Clinical suspicion for a spontaneous subarachnoid hemorrhage is high.

Arrange the following diagnostic steps in the most appropriate chronological sequence for this patient's evaluation. Assume the initial imaging scan is normal, the secondary test confirms a subarachnoid hemorrhage, and the first non-invasive vascular imaging modality fails to identify an aneurysm.

A pathologist is reviewing gastrointestinal mucosal biopsies from several patients presenting with chronic gastrointestinal symptoms. Match each of the following specific histological biopsy findings to its corresponding definitive pathologic diagnosis.

A 58-year-old man is evaluated in the clinic for a slowly enlarging, painless mass in the right side of his neck that he first noticed two months ago. He reports no fevers, drenching night sweats, or unintentional weight loss. Physical examination reveals a 3.5-cm, firm, mobile, non-tender right cervical lymph node. The remainder of the examination is unremarkable. An excisional lymph node biopsy is performed.

The histopathologic evaluation reveals complete effacement of the normal lymph node architecture by closely packed, uniform nodular structures. These nodules lack well-defined mantle zones and are devoid of tingible body macrophages.

A synoptic immunohistochemical (IHC) profile of the neoplastic cells is provided:

Based on the pathology and biopsy interpretation, which of the following is the most likely diagnosis?

A 74-year-old man is brought to the emergency department due to the abrupt onset of severe abdominal pain that began 3 hours ago. He describes the pain as generalized and constant, with an intensity of 10/10. His medical history is significant for atrial fibrillation, hypertension, hyperlipidemia, and chronic kidney disease stage 3. He was prescribed apixaban but admits to missing multiple doses over the past week. His temperature is 37.3°C (99.1°F), blood pressure is 145/85 mm Hg, heart rate is 118/min and irregularly irregular, and respiratory rate is 22/min. On physical examination, the abdomen is soft and non-distended. There is mild, diffuse tenderness to deep palpation, but no guarding, rigidity, or rebound tenderness. Bowel sounds are decreased. Laboratory results are as follows:

Hemoglobin: 13.8 g/dL
Leukocyte count: 16,500/mm³
Platelet count: 240,000/mm³
Blood urea nitrogen: 42 mg/dL
Serum creatinine: 2.6 mg/dL (Baseline: 1.6 mg/dL)
Lactate: 4.5 mmol/L (Normal: 0.5–1.0 mmol/L)

Which of the following is the most appropriate next imaging study to establish the diagnosis?

A 62-year-old man is evaluated in the intensive care unit for new-onset fever, increased purulent endotracheal secretions, and worsening oxygenation. He was intubated 6 days ago for severe blunt chest trauma following a motor vehicle collision. His medical history is significant for a severe, IgE-mediated anaphylactic allergy to penicillin, documented as causing diffuse urticaria, angioedema, and respiratory failure. Vital signs show a temperature of 39.2°C (102.6°F), heart rate of 122/min, and blood pressure of 82/45 mmHg despite the administration of 3 liters of intravenous crystalloid. He is started on a norepinephrine infusion. A chest radiograph reveals a new dense infiltrate in the right lower lobe. The patient requires prompt initiation of empiric antimicrobial therapy for suspected ventilator-associated pneumonia and septic shock. Which of the following antimicrobial agents should be included in this patient's empiric regimen? (Select all that apply)

A 68-year-old man is evaluated in the hospital for a 3-week history of progressively worsening lower back pain. The pain is continuous, wakes him up at night, and is not relieved by rest or over-the-counter analgesics. He also reports intermittent chills. Medical history includes type 2 diabetes mellitus and a recent hospitalization one month ago for a complicated urinary tract infection. Temperature is 38.2°C (100.8°F), blood pressure is 130/80 mmHg, pulse is 92/min, and respiratory rate is 16/min. Physical examination reveals focal tenderness to percussion over the lower lumbar spine. Neurological examination of the lower extremities shows full strength, intact sensation, and normal deep tendon reflexes. Laboratory studies show an erythrocyte sedimentation rate of 85 mm/h and C-reactive protein of 45 mg/L. Blood cultures are drawn. Magnetic resonance imaging (MRI) of the lumbar spine with and without gadolinium contrast reveals decreased signal intensity on T1-weighted images and increased signal intensity on T2-weighted images involving the L4 and L5 vertebral bodies. There is destruction of the intervening L4-L5 intervertebral disc with enhancement of the disc space and adjacent vertebral endplates. No epidural fluid collection or spinal cord compression is visualized.

Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in management?