All practice questions

During a routine annual physical examination, a physician identifies a neck mass in a 45-year-old female patient. The patient reports she has felt completely well and has not noticed the lump herself. A detailed review of systems is negative for unintentional weight changes, heat or cold intolerance, resting tremors, dysphagia, or hoarseness. Her past medical history is notable only for mild primary hypertension well-controlled on amlodipine. She has no personal or family history of radiation exposure or endocrine malignancies. On palpation of the neck, there is a discrete, 1.5-cm, firm, and freely mobile nodule located in the right lobe of the thyroid gland. The gland is otherwise normal in size and consistency, and there is no palpable cervical lymphadenopathy. Vital signs are within normal limits.

Which of the following diagnostic studies are indicated as the most appropriate immediate next steps in the evaluation of this patient? (Select exactly 2)

During a routine follow-up visit, an individual managed for a chronic mood disorder reports a bothersome requirement to consume large volumes of water and awaken multiple times nightly to urinate. This symptom pattern has progressively worsened over the last six months. Current daily medications include lithium carbonate and citalopram. Vital signs indicate a blood pressure of 118/76 mmHg and a heart rate of 82/min. Initial laboratory assessment yields the following results:

The clinician initiates a water deprivation test. After several hours, the serum osmolality reaches 305 mOsm/kg, while the urine osmolality remains low at 155 mOsm/kg. Following a subcutaneous injection of exogenous desmopressin, a repeat urine osmolality is measured at 165 mOsm/kg.

Based on the diagnostic evaluation, which of the following is the most likely underlying diagnosis?

A 34-year-old woman is brought to the emergency department by paramedics after being struck by a commercial delivery truck while in a crosswalk. She was thrown approximately 8 meters. Upon arrival, she is obtunded with gurgling, inadequate respirations. Vital signs are temperature 35.8°C (96.4°F), blood pressure 70/30 mmHg, pulse 148/min, and respirations 36/min. Physical examination reveals marked tracheal deviation to the left and hyperresonance with completely absent breath sounds over the right hemithorax. Her extremities are cold, and her pelvis feels mechanically unstable on gentle palpation.

Arrange the following initial stabilization steps in the correct chronological sequence according to the Advanced Trauma Life Support (ATLS) primary survey protocol.

An internal medicine physician is urgently called to the medical admission unit to evaluate a patient with acute right-sided flank pain and rigors. The patient, a 64-year-old female, reports that her symptoms started abruptly yesterday. Initial vitals demonstrate a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $86/54\text{ mm Hg}$, heart rate of $122/\text{min}$, and respiratory rate of $22/\text{min}$. On examination, exquisite tenderness is elicited over the right costovertebral angle. Laboratory analysis reveals a leukocytosis of $18,500/\text{mm}^3$ and a serum creatinine of $1.8\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$). A catheterized urine specimen yields positive results for leukocyte esterase, nitrites, and abundant bacteria. Intravenous fluid resuscitation with 2 liters of crystalloid is immediately administered, yielding a blood pressure improvement to $110/70\text{ mm Hg}$. Clinical suspicion is high for an infected obstructing ureteral calculus.

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

A 52-year-old woman presents to the outpatient clinic with a 2-day history of dysuria, urinary frequency, and suprapubic discomfort. She has a history of a mechanical mitral valve replacement for which she takes warfarin. Her most recent international normalized ratio (INR), checked 2 days ago, was 2.8. She has no fever, chills, vaginal discharge, or flank pain. Vital signs are temperature 37.1°C (98.8°F), heart rate 82/min, blood pressure 124/78 mm Hg, and respiratory rate 14/min. Physical examination reveals mild suprapubic tenderness but no costovertebral angle tenderness. Urinalysis shows positive leukocyte esterase, positive nitrites, and $>50$ white blood cells/hpf. She has no known drug allergies and her renal function is normal. Which of the following is the most appropriate pharmacologic management for this patient?

A $48$-year-old woman comes to the pulmonology clinic due to progressive shortness of breath over the past $4$ months. Initially, she noticed breathlessness only when climbing stairs, but she now feels short of breath after walking a single block on level ground. She has a medical history of severe gastroesophageal reflux disease and Raynaud phenomenon, for which she takes omeprazole and amlodipine. She has never smoked. Her blood pressure is $115/72$ mmHg, pulse is $86$/min, and respirations are $18$/min. Pulse oximetry is $96\%$ on room air at rest, but drops to $89\%$ during a $6$-minute walk test.

Physical examination reveals tight, thickened skin over her fingers and face, with several small, dilated blood vessels visible on her cheeks. Auscultation of the lungs is clear bilaterally. Cardiovascular examination reveals a prominently split second heart sound with a loud pulmonary component, and a holosystolic murmur at the left lower sternal border that becomes louder with inspiration. There is trace bilateral lower extremity edema.

Laboratory evaluation shows a positive antinuclear antibody (ANA) titer at $1:640$ with a centromere pattern.

Pulmonary function tests (PFTs) are performed with the following results:

Based on the patient's presentation and diagnostic findings, which of the following is the most likely diagnosis?

Emergency medical services bring a male construction worker to the trauma bay after he fell from a $15$-foot scaffolding. The patient, who is $42$ years old, is immobilized on a backboard with a cervical collar in place. He complains of severe pain in his left chest and significant shortness of breath. Initial vital signs show a blood pressure of $118/76$ mmHg, a heart rate of $108$/min, a respiratory rate of $26$/min, and an oxygen saturation of $94\%$ while receiving $4$ L/min of supplemental oxygen via nasal cannula. Auscultation reveals slightly diminished breath sounds on the left side, though a full examination is limited by the patient's discomfort. Point-of-care laboratory studies demonstrate a leukocyte count of $14,000/\text{mm}^3$ and a hemoglobin level of $13.8$ g/dL. A portable anteroposterior chest radiograph is obtained with the patient remaining in the supine position. The resulting image reveals an abnormally deep, hyperlucent left costophrenic angle that extends caudally toward the upper abdomen, without a visible pleural line at the lung apex. The mediastinal silhouette is midline. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in management?

A 62-year-old man with a 40-pack-year smoking history is evaluated in the clinic after a routine pre-operative chest radiograph reveals an incidental 14-mm solitary pulmonary nodule in the right upper lobe. He is entirely asymptomatic. Vital signs are within normal limits, and physical examination is unremarkable. Arrange the following steps in the most appropriate standard clinical sequence for the diagnostic workup of this patient's pulmonary finding.

A $28$-year-old man with a history of type $1$ diabetes mellitus is brought to the emergency department complaining of severe nausea, vomiting, and diffuse abdominal pain for the past $24$ hours. He reports missing several doses of his basal insulin due to a recent gastrointestinal illness. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate of $124$/min, blood pressure of $96/58$ mmHg, and respiratory rate of $24$/min with deep, rapid breaths. Laboratory studies reveal:

Serum glucose: $580$ mg/dL
Serum sodium: $134$ mEq/L
Serum potassium: $4.6$ mEq/L
Serum chloride: $98$ mEq/L
Serum bicarbonate: $12$ mEq/L
Arterial pH: $7.22$
Urinalysis: $3+$ ketones

Arrange the following pharmacologic interventions in the most appropriate chronological sequence for the management of this patient, from initial presentation to clinical resolution.

A 68-year-old woman is admitted to the hospital with a 3-day history of fever, productive cough, and progressive shortness of breath. Medical history is significant for nonvalvular atrial fibrillation, essential hypertension, and major depressive disorder. Her current home medications include apixaban, sotalol, lisinopril, and escitalopram. Her temperature is 38.4°C (101.1°F), blood pressure is 132/82 mmHg, pulse is 88/min, and respirations are 22/min. Pulse oximetry shows 93% on room air. Physical examination reveals bronchial breath sounds and crackles in the right lower lung field. Laboratory studies show a leukocyte count of 14,500/mm³. Serum creatinine is 0.9 mg/dL and electrolytes are within normal limits. A chest radiograph demonstrates a right lower lobe consolidation. An electrocardiogram shows normal sinus rhythm with a QTc interval of 520 ms. The patient is diagnosed with non-severe community-acquired pneumonia requiring inpatient management. Which of the following is the most appropriate empiric pharmacotherapy for this patient's infection?

Paramedics transport a 29-year-old female to the acute care bay after she collapsed at a grocery store. En route, the patient regained partial consciousness but remained confused and complained of excruciating lower abdominal cramping. She has no known chronic medical conditions. Upon arrival, the patient appears ashen and is actively sweating. Vital signs show a temperature of 36.7°C (98.0°F), blood pressure of 74/42 mm Hg, heart rate of 138/min, and respiratory rate of 26/min. Oxygen saturation is 99% on ambient air. The abdomen is distended, with significant guarding and rigidity noted across all quadrants. A rapid bedside urine human chorionic gonadotropin test is positive. Which of the following are the most appropriate simultaneous initial steps in the stabilization of this patient? (Select 2 options)

A 45-year-old man is brought to the emergency department by his family due to altered mental status, severe muscle stiffness, and high fever that began 24 hours ago. His medical history is significant for schizoaffective disorder, for which he has been taking clozapine and lithium for several years. Two days ago, he was prescribed oral haloperidol at an urgent care clinic for an acute exacerbation of severe agitation.

Vital signs are temperature 39.4°C (102.9°F), pulse 122/min, respirations 22/min, and blood pressure 168/100 mmHg. Physical examination reveals a diaphoretic, confused man. Neurologic examination is notable for severe, generalized "lead-pipe" muscle rigidity and decreased bowel sounds. Hyperreflexia and clonus are absent.

Laboratory studies show:
Leukocyte count: 16,500/mm³
Serum creatine kinase: 15,400 U/L
Serum creatinine: 2.1 mg/dL (baseline 0.9 mg/dL)

Which of the following pharmacologic interventions are appropriate in the management of this patient's current condition? (Select all that apply)

A 65-year-old man presents to the clinic with a 2-month history of worsening fatigue, generalized weakness, constipation, and increased frequency of urination. He also reports an unintentional weight loss of $6 \text{ kg}$ ($13.2 \text{ lb}$) during this time. His wife notes that he has become increasingly forgetful and confused over the past week. He has a 45-pack-year smoking history and a chronic morning cough but denies hemoptysis or bone pain. Vital signs are within normal limits. Physical examination reveals a cachectic appearance and scattered end-expiratory wheezes bilaterally. Laboratory evaluation is significant for a serum calcium level of $13.8 \text{ mg/dL}$ (normal: $8.4-10.2 \text{ mg/dL}$), serum albumin of $3.2 \text{ g/dL}$, and serum creatinine of $1.7 \text{ mg/dL}$ (normal: $0.6-1.2 \text{ mg/dL}$).

Based on the patient's clinical presentation, arrange the following diagnoses in order from most likely to least likely:

Match the following clinical presentations of suspected gastrointestinal bleeding with the most appropriate next step in their diagnostic sequencing.

Paramedics transport a 74-year-old male resident of an assisted living facility to the acute care triage area. The facility staff reported that he has been complaining of worsening lower abdominal discomfort and has had three episodes of bilious vomiting since yesterday evening. His medical history includes hypertension, benign prostatic hyperplasia, and mild vascular dementia. On arrival, his temperature is 38.3°C (100.9°F), blood pressure is 102/60 mmHg, heart rate is 118/min, and respiratory rate is 20/min. Physical examination reveals a $4 \times 5$ cm firm mass in the right inguinal region. The mass is exquisitely tender to palpation and cannot be reduced into the peritoneal cavity. The skin overlying the mass is warm and displays a dark purplish discoloration. Laboratory testing shows a leukocyte count of $16,500/\mu L$. Which of the following is the most appropriate next step in the management of this patient?

A 75-year-old man is brought to the emergency department from a skilled nursing facility due to a 2-day history of progressive abdominal distension, colicky abdominal pain, and obstipation. His medical history is significant for Parkinson disease, chronic constipation, and hypertension. His temperature is 37.1°C (98.8°F), blood pressure is 138/86 mmHg, heart rate is 92/min, and respiratory rate is 18/min. Physical examination reveals a markedly distended, tympanitic abdomen with mild, diffuse tenderness. There is no guarding, rigidity, or rebound tenderness. Laboratory studies show a leukocyte count of 9,500/mm³. An upright plain abdominal radiograph is obtained and demonstrates a massive, ahaustral, dilated loop of large bowel forming a U-shape that originates from the pelvis and extends toward the right upper quadrant. There is a noticeable absence of rectal gas. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in management?

A $32$-year-old woman is brought to the emergency department by her family due to profound confusion, agitation, and a high fever. She has a history of Graves disease but stopped taking her prescribed medications three months ago. On presentation, her temperature is $39.8^\circ \text{C}$ ($103.6^\circ \text{F}$), blood pressure is $160/70$ mm Hg, heart rate is $155$/min and irregular, and respiratory rate is $24$/min. Physical examination reveals a restless, diaphoretic patient with prominent exophthalmos, a diffusely enlarged and non-tender thyroid gland, a fine tremor in her outstretched hands, and a faint yellowing of her sclerae. An electrocardiogram confirms atrial fibrillation with a rapid ventricular response. A clinical diagnosis of thyroid storm is made. Arrange the following pharmacologic agents in the correct chronological sequence for the protocolized management of this patient's endocrine emergency.

An $82$-year-old woman is brought to the emergency department due to unrelenting right lower extremity pain. She was found by her neighbor on the floor of her apartment. The patient states the pain began abruptly $16$ hours ago. Her medical history includes type $2$ diabetes mellitus, hypertension, and paroxysmal atrial fibrillation. She is not taking oral anticoagulants. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $158/92\text{ mm Hg}$, pulse $115/\text{min}$ and irregularly irregular, and respirations $18/\text{min}$. On physical examination, the right lower extremity is cyanotic, mottled, and cold to the touch from the mid-thigh down. Capillary refill is absent. The patient has complete loss of sensation to pinprick and light touch below the knee. She is unable to move her toes or ankle, and the calf muscles are rigid and tender to palpation. Bedside Doppler ultrasonography reveals absent arterial and venous signals in the right foot. Which of the following is the most appropriate next step in the management of this patient's right lower extremity?

Match each laboratory profile of hypercalcemia with its most likely diagnostic etiology.

A 58-year-old man is brought to the emergency department by his family due to confusion, fever, and worsening abdominal swelling over the past 48 hours. His medical history is significant for alcohol-associated cirrhosis, portal hypertension, and prior esophageal variceal banding. Current home medications include spironolactone, furosemide, and nadolol. Vital signs show a temperature of 38.3°C (100.9°F), blood pressure of 96/58 mmHg, and heart rate of 105/min. Physical examination reveals scleral icterus, a distended abdomen with shifting dullness, and diffuse abdominal tenderness to palpation without rebound or guarding. The patient is disoriented to time and place, and asterixis is present on wrist extension.

Pertinent laboratory results are as follows:

Diagnostic paracentesis is performed, yielding cloudy ascitic fluid with a polymorphonuclear (PMN) cell count of 650/mm³.

Which of the following pharmacologic interventions are appropriate to initiate simultaneously in this patient? (Select all that apply)