All practice questions

A $35$-year-old woman presents to the outpatient clinic reporting a $3$-month history of unintentional weight loss, frequent palpitations, and increased sweating. She also reports feeling unusually anxious and having difficulty sleeping. Her vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $138/82\text{ mm Hg}$, heart rate $110\text{/min}$, and respiratory rate $16\text{/min}$. Physical examination reveals a staring gaze and mild exophthalmos. Palpation of the neck demonstrates a symmetrically enlarged, non-tender thyroid gland, and a vascular bruit is auscultated over the gland. Her skin is warm and moist. Which of the following additional physical examination findings is most specific for the underlying cause of this patient's condition?

A 78-year-old woman is brought to the emergency department from an assisted living facility due to a 3-day history of progressively worsening nausea, intractable vomiting, and abdominal distension. Her medical history includes coronary artery disease, hypertension, and symptomatic cholelithiasis for which she declined surgery two years ago. Temperature is 37.7°C (99.9°F), blood pressure is 108/68 mm Hg, pulse is 104/min, and respirations are 18/min. Physical examination reveals a distended and tympanic abdomen with high-pitched, hyperactive bowel sounds. There is diffuse mild tenderness but no guarding or rebound. A non-contrast computed tomography (CT) scan of the abdomen and pelvis reveals markedly dilated loops of small bowel measuring up to 4.5 cm in diameter. A distinct transition point is visualized in the terminal ileum, immediately proximal to a 3.5-cm, round, hyperdense laminated structure. Additionally, branching tubular lucencies are noted within the liver parenchyma; these lucencies are predominantly centrally located near the hepatic hilum. Based on these imaging findings, which of the following is the most appropriate next step in management?

Match each clinical presentation with the most appropriate next step in the diagnostic sequence.

A 68-year-old male is in the intensive care unit receiving invasive mechanical ventilation for severe acute respiratory distress syndrome secondary to influenza pneumonia. Over the past 10 minutes, the ventilator alarms for persistently high peak airway pressures. His blood pressure drops precipitously to 68/40 mm Hg, and his heart rate increases to 142/min. Oxygen saturation decreases from 94% to 81%. On physical examination, the trachea is visibly deviated to the left. Auscultation reveals completely absent breath sounds over the right hemithorax, with hyperresonance to percussion. The neck veins are severely distended.

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

A 52-year-old man is evaluated in the ambulatory care center for a 3-month history of progressive muscle weakness. He reports increasing difficulty rising from low chairs and lifting objects above his head. Over the past month, he has also developed a violaceous, erythematous rash on his upper eyelids and scaling, erythematous papules over his metacarpophalangeal joints. He reports an unintentional 6-kg (13.2-lb) weight loss during this period. His past medical history is notable for mild osteoarthritis. He has had no previous surgeries. He does not use tobacco or illicit drugs and consumes alcohol occasionally. He takes no daily medications or dietary supplements. Vital signs are within normal limits. Physical examination confirms 3/5 strength in the proximal muscle groups of the upper and lower extremities symmetrically. Reflexes are 2+ and symmetric. Sensation is intact. Based on the most likely diagnosis, eliciting a detailed history regarding which of the following is the most critical next step in this patient's evaluation?

Match each patient presentation to the most appropriate next step in diagnostic imaging.

A 42-year-old woman is evaluated for progressive weight gain, easy bruising, and proximal muscle weakness over the past 8 months. Blood pressure is 158/96 mmHg. Physical examination reveals central adiposity, facial plethora, and broad violaceous striae on her abdomen. Initial laboratory testing confirms endogenous hypercortisolism with a 24-hour urine free cortisol of 145 mcg/24h (normal: 4-50 mcg/24h) and a 1-mg overnight dexamethasone suppression test demonstrating a morning serum cortisol of 12 mcg/dL (normal: <1.8 mcg/dL). Which of the following is the most appropriate next step in the diagnostic workup?

A 33-year-old primigravida at 36 weeks gestation is brought to the emergency department by her partner due to a 2-day history of progressive nausea, vomiting, and dull right upper quadrant abdominal pain. Over the last 12 hours, she has become increasingly lethargic and confused. Her pregnancy had been uncomplicated until now. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $142/88\text{ mmHg}$, heart rate is $108/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals scleral icterus and a gravid uterus. There is marked tenderness to palpation in the right upper quadrant. Neurological examination shows a somnolent patient who is oriented to person only.

Laboratory studies show:

Peripheral blood smear shows multiple schistocytes.

Which of the following is the most likely diagnosis?

A 49-year-old man comes to the clinic reporting a one-week history of worsening lower back and right flank pain, accompanied by subjective fevers and chills. He has a history of type 2 diabetes mellitus and recently recovered from a staphylococcal skin infection on his right thigh. His temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $128/78\text{ mm Hg}$, and pulse is $98\text{/min}$. On physical examination, the patient prefers to lie supine with his right hip slightly flexed. Passive extension of the right hip elicits severe pain in the right flank and lower abdomen. However, passive internal and external rotation of the right hip while flexed do not cause significant discomfort. There is no costovertebral angle tenderness, and a straight-leg raise test is negative. Based on these physical examination findings, which of the following is the most likely diagnosis?

A 68-year-old man presents to the emergency department complaining of sudden-onset shortness of breath and right-sided pleuritic chest pain that began 2 hours ago. He underwent a right total hip arthroplasty 10 days ago. His medical history includes type 2 diabetes mellitus and hypertension. Temperature is 37.1°C (98.8°F), blood pressure is 138/86 mmHg, pulse is 112/min, and respirations are 24/min. Oxygen saturation is 91% on room air. Physical examination reveals clear lungs bilaterally and a normal cardiovascular examination. His right thigh is slightly swollen consistent with recent surgery, but there is no calf tenderness or erythema. Laboratory results show a serum creatinine level of 2.6 mg/dL (baseline 1.2 mg/dL). A bedside chest radiograph is unremarkable. Which of the following is the most appropriate next imaging study to establish the diagnosis?

A 38-year-old woman is evaluated in the outpatient clinic for a 2-month history of palpitations, increased sweating, and an unintended weight loss of 4 kg (8.8 lb). She has no significant past medical history and takes no medications. Vital signs include a blood pressure of 135/85 mm Hg and a heart rate of 112/min. Physical examination reveals a mild fine tremor of the outstretched hands and a palpable, firm, non-tender nodule in the right lobe of the thyroid gland. There is no cervical lymphadenopathy. A targeted ultrasound of the neck demonstrates a 2.2-cm solid, markedly hypoechoic nodule in the right thyroid lobe with microcalcifications and irregular margins. Laboratory studies show:

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

A 62-year-old man with a 40-pack-year smoking history undergoes a routine preoperative chest radiograph prior to an elective inguinal hernia repair. The radiograph reveals a $1.5$ cm solitary, non-calcified peripheral opacity in the right upper lobe. The patient is asymptomatic, with no cough, hemoptysis, or weight loss. Vital signs are within normal limits, and physical examination is unremarkable.

Arrange the following diagnostic imaging and interventional steps in the most appropriate chronological sequence for evaluating this patient's solitary pulmonary nodule. Assume that each step yields findings that raise the suspicion of malignancy, thereby necessitating the subsequent procedure.

An established 51-year-old male patient comes to the clinic for follow-up of medication-resistant hypertension. His blood pressure remains consistently above 150/90 mmHg despite documented adherence to a daily regimen consisting of maximally tolerated doses of amlodipine, lisinopril, and chlorthalidone. A routine comprehensive metabolic panel reveals a serum potassium concentration of 2.8 mEq/L. The clinical picture is highly suspicious for primary hyperaldosteronism. Arrange the following diagnostic and evaluative steps in the most appropriate evidence-based sequence, progressing from initial investigation to definitive pre-surgical assessment.

An unresponsive 74-year-old woman is brought to the emergency department by emergency medical services after being found on the floor of her apartment by her daughter. The daughter notes that the patient had been increasingly disoriented and complaining of excessive thirst and urination over the past week.

Past medical history: Type 2 diabetes mellitus, hypertension, hyperlipidemia.

Vital signs:
- Temperature: 37.0°C (98.6°F)
- Blood pressure: 92/58 mm Hg
- Heart rate: 118/min
- Respirations: 16/min

Physical examination shows an obtunded patient with dry mucous membranes, decreased skin turgor, and a delayed capillary refill of 4 seconds.

What is this patient's calculated serum osmolality in mOsm/kg?

A 62-year-old woman with a 40-pack-year smoking history is evaluated in the clinic for preoperative clearance prior to an elective total knee arthroplasty. She is generally healthy and reports no cough, hemoptysis, dyspnea, or weight loss. A routine preoperative chest radiograph reveals an incidental 14-mm, non-calcified, solitary nodule in the periphery of the right upper lobe. Arrange the following diagnostic modalities in the most appropriate sequential order for the evaluation of this radiographic finding, from the immediate next step to the definitive diagnostic procedure. Assume that at each step, the findings remain highly suspicious for primary pulmonary malignancy but lack definitive tissue diagnosis.

A 52-year-old man presents to the clinic with a 2-month history of worsening fatigue, early satiety, and left upper quadrant abdominal discomfort. He has no other significant past medical history and takes no medications. Vital signs are within normal limits. Physical examination is notable for massive splenomegaly extending to the umbilicus. No hepatomegaly or peripheral lymphadenopathy is appreciated.

Laboratory studies show:
Leukocyte count: 85,000/mm³ (neutrophils 55%, bands 15%, metamyelocytes 10%, myelocytes 12%, promyelocytes 3%, blasts 2%, basophils 3%)
Hemoglobin: 10.5 g/dL
Platelets: 450,000/mm³

Based on the clinical presentation and laboratory findings, arrange the following diagnoses from highest to lowest pre-test probability.

Emergency medical services bring an $81$-year-old male to the emergency department due to the abrupt onset of right-sided lower abdominal pain and an inability to bear weight on his right leg. The symptoms started $3$ hours ago while he was resting in his chair at an assisted living facility. His medical history is significant for permanent atrial fibrillation, essential hypertension, and benign prostatic hyperplasia. His current medications include rivaroxaban, lisinopril, and tamsulosin.

On presentation, his blood pressure is $88/54\text{ mmHg}$, and his pulse is $118/\text{min}$ and irregularly irregular. He appears pale, diaphoretic, and anxious. Abdominal examination reveals a soft, non-distended abdomen with localized tenderness in the right lower quadrant. There is no rebound tenderness, guarding, or pulsatile mass. Bowel sounds are normoactive. Neurological examination of the right lower extremity reveals $3/5$ strength in hip flexion and decreased pinprick sensation over the anterior thigh. Strength and sensation are fully intact in the left lower extremity. Distal pulses are $2+$ and symmetric bilaterally.

Laboratory studies show:
Hemoglobin: $7.8\text{ g/dL}$ (baseline $12.1\text{ g/dL}$ one month ago)
Leukocyte count: $8,400/\text{mm}^3$
Platelet count: $180,000/\text{mm}^3$
Serum creatinine: $1.1\text{ mg/dL}$

Which of the following is the most likely diagnosis?

While working in the emergency department, a physician evaluates a 64-year-old male patient who just arrived via private vehicle. The patient reports the abrupt onset of excruciating, tearing pain in his anterior chest that radiates directly between his shoulder blades. He has a history of long-standing, poorly controlled hypertension and heavy tobacco use. Upon initial assessment, he appears diaphoretic and in severe distress. Vital signs show a heart rate of 112/min, respiratory rate of 22/min, and a notable blood pressure discrepancy: 196/105 mmHg in the right arm and 142/86 mmHg in the left arm. Neurological examination is notable for new 3/5 motor weakness in the left lower extremity. Based on this clinical evaluation, arrange the following differential diagnoses from the highest pre-test probability to the lowest.

A 62-year-old woman is evaluated in the intensive care unit for new-onset toe pain. She was admitted 5 days ago for a massive pulmonary embolism and has been receiving a continuous intravenous unfractionated heparin infusion. Her temperature is 37.2°C (99.0°F), blood pressure is 138/86 mm Hg, and pulse is 98/min. Physical examination reveals dark purple discoloration and ischemic changes in the toes of her left foot. Laboratory studies show a platelet count of 88,000/mm³, a significant decrease from her admission platelet count of 250,000/mm³. A presumptive diagnosis of heparin-induced thrombocytopenia (HIT) with arterial thrombosis is made, and anti-platelet factor 4 (PF4) antibody testing is ordered.

Arrange the following pharmacologic management steps in the required chronological sequence according to standard treatment protocols for this condition.

Match each clinical presentation with the single most appropriate initial or next step in diagnostic imaging.