All practice questions

Match each patient's specific occupational and environmental exposure history to the most likely associated pulmonary diagnosis.

A 42-year-old woman presents to the clinic complaining of severe, generalized muscle weakness over the past few days. She also reports a one-year history of a gritty sensation in her eyes and needing to drink water frequently due to a persistently dry mouth. Vital signs are within normal limits. Laboratory results are obtained as follows:

Based on the provided laboratory findings, which of the following is the most likely diagnosis?

A $65$-year-old man is evaluated in the clinic for progressively worsening fatigue, constipation, and an unintended $4\text{-kg}$ ($8.8\text{-lb}$) weight gain over the past three months. His medical history is notable for ischemic cardiomyopathy and refractory atrial fibrillation, for which a new antiarrhythmic medication was initiated six months ago. Vital signs show a heart rate of $55/\text{min}$ and blood pressure of $110/70\text{ mm Hg}$. Physical examination reveals delayed relaxation of the deep tendon reflexes and dry, coarse skin. Laboratory testing shows a serum thyroid-stimulating hormone (TSH) level of $18.4\text{ mIU/L}$ (reference: $0.5-5.0\text{ mIU/L}$) and a free thyroxine (T4) level of $0.5\text{ ng/dL}$ (reference: $0.9-1.7\text{ ng/dL}$). Which of the following is the most likely primary cellular mechanism responsible for this patient's current endocrine laboratory abnormalities?

A 52-year-old male immigrant from rural Honduras is admitted to the inpatient medical ward with a newly developed diffuse, serpiginous pruritic rash on his trunk, intermittent wheezing, and a low-grade fever. He recently completed a 14-day course of trimethoprim-sulfamethoxazole for a presumed prostate infection. Laboratory evaluation is notable for a leukocyte count of 12,500/mm³ with 18% eosinophils. A chest radiograph demonstrates patchy bilateral infiltrates. The admitting team diagnoses a severe drug hypersensitivity reaction (e.g., DRESS syndrome) secondary to the recent antibiotic use and prepares to administer high-dose intravenous methylprednisolone. Before initiating this immunosuppressive therapy, which of the following aspects of the patient's medical history is most critical to elucidate?

An evaluation of a $68$-year-old retired mechanic is prompted by a $3$-month history of severe, non-radiating mid-back pain and progressive fatigue. He reports no recent trauma but notes he has been increasingly constipated and urinating more frequently than usual. Vital signs are within normal limits. Physical examination reveals point tenderness over the L $3$ and L $4$ vertebrae. Laboratory investigations demonstrate a hemoglobin of $8.9 \text{ g/dL}$, serum calcium of $11.6 \text{ mg/dL}$, and serum creatinine of $2.1 \text{ mg/dL}$. A peripheral blood smear shows red blood cells stacked like coins. Serum protein electrophoresis reveals a sharp monoclonal peak in the gamma region. A subsequent skeletal survey displays multiple punched-out radiolucent lesions in the skull and lumbar spine. Which of the following best describes the primary underlying neoplastic process responsible for this patient's radiologic findings?

A 62-year-old woman is evaluated in the emergency department for a 5-day history of progressive shortness of breath, dry cough, and subjective fevers. Her past medical history is notable for severe, erosive rheumatoid arthritis, for which she has been treated with methotrexate and etanercept for the past three years. Her temperature is 37.9°C (100.2°F), blood pressure is 128/76 mmHg, pulse is 108/min, and respiratory rate is 24/min. Pulse oximetry is 89% on room air. Lung auscultation reveals fine, bilateral basilar crackles. Chest radiography demonstrates diffuse, bilateral, ground-glass interstitial opacities. Which of the following elements of this patient's medical history are MOST critical to elicit to guide the immediate diagnostic workup? (Select all that apply)

A 75-year-old woman is brought to the outpatient clinic by her son due to a 2-week history of progressive lethargy, intermittent confusion, and two recent mechanical falls. Her medical history includes heart failure with preserved ejection fraction, hypertension, osteoarthritis, and generalized anxiety disorder. According to her son, her baseline cognitive function was completely intact until this recent decline. She is managed by multiple specialists, but her son is unsure of her exact medication regimen and did not bring her pill bottles. Vital signs are within normal limits. Which of the following specific historical inquiries are MOST critical to prioritize during this initial evaluation to establish the etiology of her symptoms? (Select 2)

A 41-year-old woman is evaluated in the internal medicine clinic for a 3-month history of progressive weight loss, heat intolerance, frequent palpitations, and emotional lability. She reports normal oral intake and has not changed her diet. On physical examination, her temperature is 37.4°C (99.3°F), blood pressure is 152/78 mm Hg, and pulse is 116/min and regular. The physician determines that she has thyrotoxicosis and is considering the differential diagnosis, which includes Graves' disease, toxic multinodular goiter, and silent thyroiditis. Which of the following physical examination findings would specifically point to Graves' disease as the underlying etiology? (Select all that apply)

A $61$-year-old woman with a history of advanced lung cancer presents to the emergency department complaining of severe shortness of breath, orthopnea, and dizziness that has progressively worsened over the past $3$ days. Earlier today, she felt lightheaded and nearly fainted while walking. Vital signs show a temperature of $37.1^{\circ}$ C ($98.8^{\circ}$ F), blood pressure of $84/68$ mmHg, heart rate of $124$/min, and respiratory rate of $24$/min. Her extremities are cool and clammy. Bedside electrocardiography demonstrates sinus tachycardia with low QRS voltage and beat-to-beat variation in the amplitude of the QRS complexes. The physician suspects a life-threatening accumulation of fluid in the pericardial space. Which of the following physical examination findings are most likely to be present in this patient? (Select all that apply)

A 71-year-old man with a history of poorly controlled hypertension and type 2 diabetes mellitus is evaluated in the emergency department for severe, continuous vertigo, nausea, and vomiting that began abruptly 5 hours ago. He is unable to walk unassisted due to profound unsteadiness. He reports no hearing changes, tinnitus, or recent illnesses. Blood pressure is 174/98 mm Hg.

On physical examination, the patient is in visible distress and keeps his eyes closed to minimize the spinning sensation. When his eyes are open, a spontaneous, horizontal nystagmus is observed. The nystagmus changes direction, beating to the left on leftward gaze and to the right on rightward gaze. A head impulse test is performed; as the physician rapidly turns the patient's head to either side, the patient's eyes remain steadily fixed on the physician's nose without requiring a corrective saccade. An alternating cover test demonstrates a slight vertical shift of the eyes as they uncover.

Which of the following is the most likely underlying mechanism for this patient's physical examination findings?

During a follow-up telehealth visit, a rheumatologist is evaluating a patient who was recently started on a chimeric monoclonal antibody for refractory rheumatoid arthritis. The initial infusion was administered 10 days ago without immediate complications. Today, the patient reports a 2-day history of low-grade fever, diffuse joint pain involving the wrists and ankles, and an intensely itchy rash. Photographs uploaded to the patient portal reveal widespread urticarial wheals with scattered areas of purpura. Subsequent laboratory evaluation demonstrates an elevated erythrocyte sedimentation rate and significantly reduced levels of both C3 and C4. Urinalysis shows 1+ proteinuria and 5 to 10 red blood cells per high-power field. Which of the following is the precise immunopathologic mechanism directly responsible for this patient's current clinical presentation?

During a routine ambulatory clinic visit, evaluation of a male patient in his late sixties reveals a 4-week history of progressive, painless jaundice accompanied by acholic stools, dark urine, and an unintentional 6-kg (13-lb) weight loss. His physical examination is notable for scleral icterus and a palpably enlarged, non-tender gallbladder (Courvoisier sign). Laboratory analysis demonstrates a marked elevation in total bilirubin (14.2 mg/dL) and alkaline phosphatase (720 U/L), with normal aminotransferase levels. The clinical picture is highly suspicious for a malignant extrahepatic biliary obstruction.

Arrange the following diagnostic imaging and procedural modalities in the correct step-wise sequence for evaluating this patient, where the interpretation of each study directly dictates the progression to the next step, ultimately leading to definitive tissue diagnosis and therapeutic palliation.

Evaluate the following clinical scenarios and match each patient's presentation with the most appropriate alternative or next diagnostic imaging study, taking into account their specific contraindications to first-line modalities.

A 28-year-old man comes to the clinic for a routine wellness examination. He has no physical complaints and feels well. His medical history is unremarkable, and he takes no medications. Family history is notable for a father who was told he had "high calcium" but never required surgery. Vital signs are within normal limits. Physical examination reveals no abnormalities.

Laboratory results are as follows:

Based on the interpretation of these laboratory results, which of the following is the most likely diagnosis?

As part of a quality improvement initiative, the nephrology department is reviewing the diagnostic workup algorithms for patients presenting with acute glomerulonephritis. Match the following patient clinical presentations to the most appropriate initial targeted serologic laboratory evaluation to order.

Evaluate the following multi-parameter laboratory profiles related to calcium and bone metabolism. Reference ranges: Serum Calcium $8.4-10.2$ mg/dL, Serum Phosphorus $3.0-4.5$ mg/dL, Intact PTH $15-65$ pg/mL. Match each clinical laboratory profile to its most likely underlying diagnostic etiology.

A 58-year-old man is evaluated in the intensive care unit for persistent oozing from his central venous catheter insertion site. He was admitted two days ago with a large esophageal variceal hemorrhage requiring endoscopic banding. His past medical history is significant for alcohol use disorder and advanced cirrhosis. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $105/65 \text{ mmHg}$, and pulse is $98/\text{min}$.

Laboratory studies show:

Based on the laboratory results, which of the following best explains this patient's coagulation profile?

During a clinical reasoning seminar, physicians are evaluating the importance of a detailed dietary and social history in establishing a precise diagnosis. Match each specific dietary exposure history and resulting clinical presentation to the most likely associated diagnosis.

A 34-year-old woman with a history of systemic lupus erythematosus and Sjögren syndrome is evaluated in the emergency department for progressive muscle weakness over the past 3 days. She reports difficulty climbing stairs and getting out of chairs. She has not had diarrhea or vomiting. Her blood pressure is 112/76 mm Hg, and her pulse is 88/min. Physical examination shows 3/5 motor strength in the proximal lower extremities. Laboratory results are as follows:

Serum:
Sodium: $138$ mEq/L
Potassium: $2.4$ mEq/L
Chloride: $115$ mEq/L
Bicarbonate: $13$ mEq/L

Arterial blood gas (room air):
pH: $7.27$
pCO2: $28$ mm Hg

Urine:
Sodium: $42$ mEq/L
Potassium: $35$ mEq/L
Chloride: $51$ mEq/L

To help determine the etiology of this patient's acid-base disturbance, the physician evaluates her urinary electrolytes. What is this patient's urine anion gap in mEq/L?

Match the following renal biopsy findings (including light microscopy, immunofluorescence, and electron microscopy features) to their corresponding primary glomerular disease.