All practice questions

A 65-year-old woman is brought to the emergency department by her son due to a one-week history of worsening confusion, lethargy, and severe constipation. She has also been complaining of increased thirst and frequent urination. Her past medical history is notable for hypertension, osteoporosis, and osteoarthritis of the knees. Her chronic medications include hydrochlorothiazide, amlodipine, and daily ibuprofen. The son reports that she has been experiencing frequent heartburn over the past month and has been self-medicating by consuming large quantities of over-the-counter antacid tablets. On examination, the patient is somnolent but arousable. Mucous membranes are dry.

Initial laboratory studies reveal:
Sodium: 137 mEq/L
Potassium: 3.4 mEq/L
Chloride: 96 mEq/L
Bicarbonate: 35 mEq/L
BUN: 45 mg/dL
Creatinine: 2.2 mg/dL (baseline 0.9 mg/dL)
Calcium: 14.5 mg/dL
Parathyroid hormone (PTH): 8 pg/mL (normal 10-65 pg/mL)

In addition to her recent over-the-counter antacid use, which of the following elements of this patient's medical history most significantly predisposed her to developing this specific acute laboratory presentation?

Match the following clinical and laboratory profiles of disordered mineral and bone metabolism to their primary underlying molecular or cellular mechanism.

A 72-year-old woman is evaluated in the clinic for progressive fatigue, forgetfulness, and a tingling sensation in her feet over the past 6 months. Her past medical history is notable for hypothyroidism and vitiligo. Physical examination reveals decreased vibratory sensation in the bilateral lower extremities and a smooth, beefy-red tongue. A complete blood count shows a hemoglobin of $9.4 \text{ g/dL}$ and a mean corpuscular volume of $114 \text{ fL}$. Arrange the following laboratory investigations in the most appropriate stepwise diagnostic sequence to definitively establish the diagnosis and etiology of her anemia.

Carefully review the following patient historical profiles. Match each unique occupational, travel, or exposure history to the most likely corresponding infectious diagnostic consideration.

A 62-year-old man comes to the primary care clinic reporting severe, diffuse muscle aches, profound generalized weakness, and passing dark brown urine for the past 48 hours. He has a past medical history of hyperlipidemia, essential hypertension, and paroxysmal atrial fibrillation. His surgical history is notable for an appendectomy in childhood. He consumes 1 to 2 glasses of wine per week and denies tobacco or illicit drug use. His chronic daily medications include atorvastatin, amlodipine, and metoprolol. Five days ago, he was evaluated at an urgent care center for an acute exacerbation of chronic bronchitis and was prescribed a 7-day course of an oral medication. Vital signs today are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $138/86\text{ mm Hg}$, pulse $82\text{/min}$, and respirations $16\text{/min}$. Laboratory studies reveal a serum creatine kinase level of $14,500\text{ U/L}$ and a serum creatinine of $2.1\text{ mg/dL}$ (baseline $1.0\text{ mg/dL}$). Which of the following elements of his medical and dietary history are most critical to elucidate the etiology of his current presentation? (Select all that apply)

A 23-year-old right-handed man comes to the urgent care clinic two hours after injuring his right wrist. He reports that he lost his balance while skateboarding and fell, bracing his impact with an outstretched hand and extended wrist. He complains of a deep, continuous ache on the radial aspect of his wrist. On physical examination, the overlying skin is intact and there is no visible gross deformity. He exhibits severe point tenderness in the anatomical depression located between the extensor pollicis longus and the extensor pollicis brevis tendons when his thumb is actively extended. Wrist range of motion is mildly limited secondary to pain. Posteroanterior, lateral, and specialized scaphoid views of the wrist on plain radiography are interpreted as showing no radiolucent lines, cortical step-offs, or malalignment. Based on the interpretation of these radiographic findings in the context of the patient's clinical presentation, which of the following is the most appropriate next step in management?

An 81-year-old man is brought to the emergency department after experiencing a syncopal episode while shoveling snow. He regained consciousness within one minute without intervention. His family notes he has been increasingly fatigued over the past half-year. Cardiac auscultation identifies a harsh systolic murmur at the base of the heart. Which of the following physical examination findings would most strongly suggest that the patient has severe, rather than mild, aortic stenosis? Select all that apply.

A 48-year-old woman comes to the emergency department complaining of severe, constant epigastric pain that began 8 hours ago. The pain radiates directly to her mid-back and is accompanied by persistent nausea and multiple episodes of non-bilious vomiting. She has no significant past medical history and takes no medications. She consumes a glass of wine occasionally but denies heavy alcohol use. Her temperature is 37.9°C (100.2°F), blood pressure is 135/85 mmHg, pulse is 108/min, and respiratory rate is 18/min. Physical examination reveals a non-distended abdomen with marked tenderness to palpation in the epigastrium; there is no rebound tenderness or guarding. Bowel sounds are hypoactive.

Laboratory evaluation shows:
Leukocyte count: 12,500/mm³
Serum alanine aminotransferase (ALT): 185 U/L
Serum aspartate aminotransferase (AST): 140 U/L
Serum alkaline phosphatase: 160 U/L
Serum lipase: 3,200 U/L (Reference range: 10-140 U/L)

Which of the following is the most appropriate initial imaging study for this patient?

A 59-year-old woman is diagnosed with invasive ductal carcinoma of the breast following a core needle biopsy. Subsequent surgical staging reveals involvement of the ipsilateral axillary lymph nodes, indicating that local invasion and metastasis have occurred. The process of metastasis requires primary tumor cells to breach the basement membrane, traverse the interstitial connective tissue, and enter the vascular or lymphatic circulation. Arrange the following cellular and molecular steps of tumor invasion in the correct chronological order, starting with the initial event at the primary tumor site.

A 48-year-old woman is evaluated in the pulmonary clinic for a 6-month history of progressive dyspnea on exertion and a dry, nonproductive cough. She denies fevers, chills, night sweats, or unintentional weight loss. Her past medical history is unremarkable, and she takes no daily medications. She works as an engineer in an aerospace manufacturing facility. She has never smoked cigarettes. Physical examination reveals normal breath sounds bilaterally without wheezes or crackles. High-resolution computed tomography (HRCT) of the chest demonstrates bilateral hilar lymphadenopathy and upper lobe-predominant reticulonodular infiltrates. Bronchoscopy with transbronchial biopsy reveals numerous noncaseating granulomas with no evidence of malignant cells, acid-fast bacilli, or fungal organisms. Which of the following elements from this patient's history is the most critical factor for prioritizing a specific environmental etiology over idiopathic sarcoidosis?

A 64-year-old man presents to the primary care clinic with a 3-week history of progressively worsening shortness of breath and chest tightness. He has a history of mild asthma that has been well-controlled without the need for daily controller medications for several years. His medical history is also significant for hypertension, benign prostatic hyperplasia, and primary open-angle glaucoma, which was diagnosed by an ophthalmologist one month ago. His current oral medications include lisinopril and tamsulosin. He reports no fever, chills, productive cough, or recent upper respiratory tract infections. His blood pressure is $128/82$ mmHg, pulse is $62$/min, and respirations are $18$/min. Pulse oximetry shows $96\%$ on room air. Physical examination reveals a prolonged expiratory phase with bilateral end-expiratory wheezing.

Which of the following inquiries during the medical history evaluation is most likely to reveal the etiology of this patient's current symptoms?

A 52-year-old man with stage 4 chronic kidney disease is found to have asymptomatic hypocalcemia on routine laboratory testing. To explain the pathophysiology of this finding to a medical student, the attending physician reviews the normal physiological cascade of vitamin D metabolism and its downstream effects on calcium homeostasis, highlighting the specific enzymatic step that is impaired in this patient.

Arrange the following steps of endogenous vitamin D synthesis, activation, and mechanism of action in the correct chronological order, beginning with the initial precursor in the skin.

A $34$-year-old male presents to the outpatient clinic reporting a painless rash on his hands and feet that appeared $3$ days ago. Over the past $6$ weeks, he has experienced intermittent low-grade fevers, night sweats, generalized joint aches, and a $5$-kg ($11$-lb) weight loss. One month ago, he experienced a mild upper respiratory illness that was treated with azithromycin by a telehealth provider. He has no significant past medical history, though he recalls being told he had a "harmless heart noise" as a child. He takes no daily medications and denies intravenous drug use.

Vital signs include a temperature of $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure of $128/72 \text{ mmHg}$, and heart rate of $94/\text{min}$. Physical examination reveals multiple small, erythematous, non-tender macules on the palmar and plantar surfaces, as well as a few dark red, linear streaks under the fingernails. Cardiopulmonary examination reveals a grade II/VI blowing, decrescendo diastolic murmur heard best at the right second intercostal space. The spleen is palpable $3 \text{ cm}$ below the left costal margin.

Laboratory results are as follows:
Hemoglobin: $10.4 \text{ g/dL}$
Leukocytes: $11,200/\text{mm}^3$
Platelets: $380,000/\text{mm}^3$
Creatinine: $1.5 \text{ mg/dL}$ (Baseline: $0.9 \text{ mg/dL}$)
Rheumatoid factor: $85 \text{ IU/mL}$ (Normal: $<15 \text{ IU/mL}$)

Urinalysis shows $2+$ protein, $2+$ blood, $15$-$20$ RBCs/hpf, and occasional red blood cell casts.

Which of the following is the most likely diagnosis?

Review the following four clinical vignettes detailing patients with distinct thyroid laboratory abnormalities. For each presentation, identify the underlying diagnostic entity that best explains the combined clinical and biochemical findings.

For each of the following clinical presentations, select the single most appropriate initial or next imaging modality to establish the diagnosis.

Match each distinct high-resolution computed tomography (HRCT) chest imaging finding to the most likely corresponding interstitial or occupational lung disease diagnosis.

A 64-year-old woman with a history of rheumatic mitral stenosis and atrial fibrillation presents to the emergency department reporting sudden, severe right leg pain that began 2 hours ago. She admits to running out of her prescribed anticoagulant medication three weeks ago. Vital signs include a blood pressure of $142/88 \text{ mm Hg}$ and a heart rate of $112/\text{min}$ with an irregularly irregular rhythm. Physical examination of the right lower extremity reveals a cold, pale leg with visible mottling. There is complete loss of light touch sensation over the dorsum of the foot, and the patient is unable to dorsiflex her toes. Palpation reveals a strong right femoral pulse, but popliteal, dorsalis pedis, and posterior tibial pulses are absent. Bedside continuous-wave Doppler ultrasound demonstrates absent arterial signals but audible venous signals in the right foot. Which of the following interventions are indicated in the immediate management of this patient? (Select all that apply)

A 52-year-old agricultural worker is brought to the emergency department by his coworkers. He collapsed 30 minutes ago while mixing chemicals in an enclosed, poorly ventilated greenhouse. Coworkers report he complained of severe abdominal cramps and blurred vision before losing consciousness. On arrival, the patient is unresponsive to painful stimuli. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure $85/50\text{ mm Hg}$, heart rate $42/\text{min}$, respiratory rate $10/\text{min}$, and oxygen saturation $84\%$ on room air. Examination reveals profuse diaphoresis and copious, frothy secretions emanating from his mouth. Pupils are $1\text{ mm}$ bilaterally and poorly reactive to light. Pulmonary auscultation reveals diffuse wheezing and bilateral rhonchi. Widespread muscle fasciculations are visible across his chest and extremities. Which of the following is the most appropriate initial step in the stabilization of this patient?

A 62-year-old woman is preparing for discharge to her home after a 4-day hospitalization for an exacerbation of chronic obstructive pulmonary disease. The physician is initiating the discharge medication reconciliation process to ensure a safe care transition. Arrange the standard steps of the discharge medication reconciliation process in the correct chronological sequence from first to last.

A 55-year-old man is evaluated for hospital discharge. He was admitted 3 weeks ago for severe acute necrotizing pancreatitis complicated by acute respiratory distress syndrome, requiring 14 days of mechanical ventilation in the intensive care unit. He was transferred to the general medical ward 7 days ago. His current medications include subcutaneous insulin and oral pancreatic enzyme replacement therapy. Vital signs are within normal limits, and laboratory studies show resolution of his acute kidney injury and leukocytosis. The patient is tolerating a regular diet. However, he has generalized muscle weakness and requires moderate physical assistance from two people to transfer from the bed to a chair. He cannot ambulate independently. During physical therapy evaluation, he demonstrates high motivation and successfully participates in 3.5 hours of combined physical and occupational therapy without excessive fatigue. He lives in a single-story home with his wife, who works full-time during the day. Which of the following is the most appropriate disposition for this patient?