All practice questions

An outpatient internal medicine clinic identifies that only 45% of patients with diabetes mellitus have a documented annual comprehensive foot examination, which is significantly below the national benchmark. The clinic's quality improvement committee decides to utilize the Plan-Do-Study-Act (PDSA) methodology to implement a new electronic health record (EHR) reminder system. Arrange the following actions in the correct chronological sequence to represent a complete, single PDSA cycle.

A 68-year-old man with advanced idiopathic pulmonary fibrosis is admitted to an inpatient hospice unit. Over the next several days, his respiratory status declines, and he develops progressive, severe dyspnea that causes him significant distress. The medical team plans a stepwise approach to symptom management. Arrange the following interventions in the most appropriate sequential order for managing this patient's progressive terminal dyspnea, from the initial first-line approach to the final intervention of last resort for truly refractory symptoms.

A 54-year-old man with a body mass index of 34 kg/m² comes to the clinic for a follow-up visit regarding his newly diagnosed type 2 diabetes mellitus. He reports struggling to adhere to his prescribed diet and exercise regimen. Laboratory studies show a fasting plasma glucose of 145 mg/dL and a hemoglobin A1c of 7.6%. The physician initiates metformin therapy and explains that the patient's condition is primarily driven by peripheral insulin resistance, which is characterized by a blunted intracellular response to endogenous insulin in target tissues. Place the following molecular events in the correct chronological sequence representing the normal cellular mechanism of insulin-mediated glucose uptake in skeletal muscle, from initial hormone binding to the final physiological effect.

A 41-year-old woman with systemic lupus erythematosus on chronic glucocorticoid therapy presents with progressively worsening right groin pain that is exacerbated by weight-bearing. Physical examination reveals limited internal rotation of the right hip. Suspecting avascular necrosis (osteonecrosis) of the femoral head, you review the natural history of this condition to guide your diagnostic imaging strategy and patient counseling. Arrange the following characteristic imaging findings of avascular necrosis in chronological order, from the earliest initial presentation to the most advanced end-stage of the disease.

A 35-year-old man is hospitalized for the treatment of infective endocarditis and is currently receiving his first dose of intravenous penicillin G. Ten minutes into the infusion, he develops severe pruritus, a sensation of throat tightness, and sudden shortness of breath. His temperature is 37.1°C (98.8°F), blood pressure is 82/50 mm Hg, pulse is 122/min, and respirations are 26/min. Physical examination reveals diffuse urticaria across his torso and audible expiratory wheezing.

Arrange the following management and diagnostic steps in the most appropriate chronological order for this patient's acute condition.

A 65-year-old man presents to the clinic for preoperative evaluation before an elective inguinal hernia repair. A screening posteroanterior and lateral chest radiograph reveals a 1.4-cm, well-circumscribed, non-calcified opacity in the peripheral right upper lobe. He has a 40-pack-year smoking history but quit 5 years ago. He is completely asymptomatic, reporting no cough, hemoptysis, shortness of breath, or weight loss. Physical examination is unremarkable. Arrange the following diagnostic steps in the most appropriate sequential order for the evaluation of this patient's imaging finding, from the initial action to the definitive diagnostic procedure.

A 45-year-old woman presents to the dermatology clinic for evaluation of a suspicious skin lesion on her left posterior thigh. She states that a 'mole' she has had for over a decade has recently grown larger, developed irregular borders, and acquired varied shades of brown, black, and blue. Excisional biopsy confirms malignant melanoma with a Breslow depth of 1.8 mm. The foundational pathogenesis of this disease typically follows a well-described, stepwise evolution of cellular and structural changes. Arrange the following histopathologic and cellular phases of this patient's neoplastic process in the correct chronological sequence of classical development, from the earliest initial lesion to the most advanced stage.

A 68-year-old man presents to the clinic reporting progressive yellowing of his skin and eyes over the past three weeks. He has noticed dark urine, pale-colored stools, and an unintentional 5-kg (11-lb) weight loss during this time. He denies any abdominal pain, fever, or chills. Physical examination is notable for scleral icterus and a palpable, non-tender mass in the right upper quadrant. Arrange the following imaging and image-guided modalities in the most appropriate standard sequence for diagnosing and staging this patient's suspected condition, starting with the initial step.

A 44-year-old female is evaluated in the ambulatory care clinic due to progressive weight gain, easy bruising, and profound proximal muscle weakness over the past eight months. Physical examination is notable for facial plethora, prominent supraclavicular fat pads, and broad purplish abdominal striae. Her blood pressure is 158/96 mmHg. She has no history of exogenous glucocorticoid use. The physician suspects endogenous hypercortisolism.

Arrange the following diagnostic laboratory tests and procedures in the most appropriate sequential order to establish the diagnosis and identify the precise etiology.

Emergency medical services bring a 23-year-old male to the emergency department after his roommate found him diaphoretic, lethargic, and disoriented. The patient has a history of type 1 diabetes mellitus and recently increased his running mileage. Capillary blood glucose on arrival is 34 mg/dL. The physician promptly administers an intramuscular injection of a counter-regulatory peptide hormone, resulting in a rapid improvement of the patient's mental status and a steady rise in blood glucose over the next 15 minutes. Arrange the following intracellular and enzymatic steps in the correct chronological sequence detailing the hepatic mechanism by which this treatment reversed the patient's hypoglycemia.

A 62-year-old woman is evaluated in the intensive care unit for sudden-onset high fever, rigors, and altered mental status. Five days ago, she received chimeric antigen receptor (CAR) T-cell therapy for relapsed diffuse large B-cell lymphoma. Her temperature is 39.8°C (103.6°F), blood pressure is 82/45 mm Hg, pulse is 134/min, and respirations are 28/min. Oxygen saturation is 88% on room air. Physical examination reveals a lethargic patient with warm, flushed extremities. Cytokine release syndrome (CRS) is suspected, though concurrent sepsis cannot be excluded. Arrange the following management steps in the most appropriate chronological sequence for this patient's acute immunologic complication.

A 61-year-old man is diagnosed with advanced non-small cell lung cancer. Immunohistochemical analysis of his biopsy specimen reveals a high tumor mutational burden and robust expression of programmed death-ligand 1 (PD-L1). He is initiated on pembrolizumab, an immune checkpoint inhibitor. The pathogenesis of this patient's pre-treatment immune evasion relies on a specific sequence of cellular interactions collectively known as adaptive immune resistance. Arrange the following pathophysiological events in the chronological order that leads to tumor-induced T-cell anergy.

A 26-year-old individual presents to the outpatient clinic requesting sexually transmitted infection screening. He reports a high-risk, unprotected sexual encounter approximately 12 days ago. For the past 48 hours, he has experienced a sore throat, low-grade fever, myalgias, and significant fatigue. Physical examination reveals bilateral cervical lymphadenopathy. The physician suspects acute human immunodeficiency virus (HIV) infection.

Arrange the following laboratory tests in the correct sequential order for diagnosing and subsequently establishing the baseline immunological status of this patient, in accordance with the standard testing algorithm.

An emergency medicine physician evaluates a pregnant patient at 20 weeks gestation who reports acute, severe right lower quadrant abdominal pain that started 12 hours ago. She has experienced one episode of emesis and ongoing nausea. Vital signs show a temperature of 38.2°C (100.8°F), blood pressure of 110/70 mmHg, and heart rate of 105/min. On physical examination, there is pronounced focal tenderness over the right lower quadrant accompanied by voluntary guarding. Initial laboratory studies demonstrate a leukocyte count of 16,000/mm³. The clinical team strongly suspects acute appendicitis.

Arrange the following diagnostic modalities in the correct sequential order for evaluating this patient's condition, starting with the most appropriate initial step and proceeding to the final confirmatory and therapeutic step if the preceding studies are non-diagnostic or unavailable.

A 68-year-old man is brought to the emergency department with sudden-onset right-sided hemiparesis, facial droop, and global aphasia. His symptoms were first noticed by his wife 8 hours ago, and he was last known to be at his baseline 10 hours ago. His blood pressure is 165/90 mmHg, and his pulse is 88/min and irregularly irregular. Suspecting an acute ischemic stroke, the stroke team is activated to evaluate the patient for potential mechanical thrombectomy.

Arrange the following neuroimaging modalities in the most appropriate chronological sequence for the evaluation and management of this patient, from initial emergency department presentation to definitive subacute post-treatment follow-up.

A 68-year-old man is brought to the emergency department by his daughter. She reports that he has a long history of severe alcohol use disorder and was found at his apartment with a 3-day history of high fever, productive cough with thick, foul-smelling sputum, and progressive shortness of breath. Temperature is $38.9^\circ\text{C}$, blood pressure is $110/70$ mmHg, heart rate is $108$/min, and respiratory rate is $24$/min. Pulse oximetry shows $92\%$ on room air. Dental examination reveals poor dentition with severe gingivitis. Chest radiography demonstrates a $4$ cm cavitary lesion with a prominent air-fluid level located in the superior segment of the right lower lobe. Based on this patient's clinical presentation, arrange the following differential diagnoses for his cavitary lung lesion in order of their pre-test probability, from highest (most likely) to lowest (least likely).

A 65-year-old woman with a history of atrial fibrillation is evaluated for sudden-onset right-sided hemiparesis and expressive aphasia. The neurology team discusses the expected neuroimaging evolution of a large middle cerebral artery territory infarction.

Arrange the following expected magnetic resonance imaging (MRI) head findings in chronological order of their appearance, from earliest (hyperacute phase) to latest (chronic phase).

A 62-year-old woman with a history of poorly controlled type 2 diabetes mellitus, hyperlipidemia, and a 35-pack-year smoking history presents to the vascular surgery clinic. She reports severe, cramping pain in her bilateral calves that predictably occurs after walking approximately 50 meters and is promptly relieved by 5 minutes of rest. Her physical examination reveals shiny, hairless skin over the distal lower extremities, delayed capillary refill, and non-palpable dorsalis pedis pulses bilaterally. The patient states these symptoms have progressively worsened over the past six months and now significantly impair her ability to work. The clinical team determines that she is a candidate for revascularization. Arrange the following diagnostic and imaging modalities in the standard, step-wise chronological sequence utilized to evaluate her condition, map the disease, and perform the intervention.

A 28-year-old man presents to the primary care clinic for evaluation of a penile sore. He noticed the lesion approximately one week ago. He reports that it is completely painless and has not changed in size. The patient is sexually active with new male partners and reports inconsistent condom use. He has no other medical conditions and takes no medications. Vital signs are within normal limits. Physical examination reveals a 1.2-cm, well-demarcated, indurated ulcer with a clean base on the glans penis. Bilateral non-tender inguinal lymphadenopathy is also present. The physician suspects primary syphilis. The clinic laboratory utilizes the reverse sequence screening algorithm for serologic evaluation.

Arrange the following laboratory tests in the correct chronological sequence as they are performed in the reverse sequence diagnostic algorithm for this patient's suspected condition.

A $58$-year-old man with a history of hypertension undergoes an abdominal ultrasound for mild right upper quadrant pain. The ultrasound incidentally identifies a $3.2$-cm solid mass in the right adrenal gland. Subsequent biochemical screening for hypercortisolism, primary aldosteronism, and pheochromocytoma is entirely normal. Arrange the following diagnostic modalities in the correct evidence-based sequence for characterizing this adrenal incidentaloma, starting with the initial preferred imaging study and ending with the most invasive diagnostic step of last resort.