All practice questions

An internal medicine physician is evaluating a 72-year-old man for worsening renal function discovered on routine laboratory monitoring. The patient has a history of resistant hypertension that has been difficult to control despite maximum tolerated doses of amlodipine, metoprolol, and chlorthalidone. Three weeks ago, lisinopril was added to his medication regimen to achieve better blood pressure control. The patient currently feels well and denies any headache, chest pain, shortness of breath, or changes in urination.

Vital signs today show a blood pressure of 182/98 mmHg and a heart rate of 74/min. Physical examination is notable for a high-pitched holosystolic murmur heard best over the right upper quadrant of the abdomen.

Current laboratory studies are compared to baseline from three weeks ago:

Urinalysis reveals no red blood cells, white blood cells, or casts.

Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's hypertension?

A 32-year-old woman is brought to the emergency department by her husband after experiencing a witnessed generalized tonic-clonic seizure. The patient is 3 weeks postpartum following an uncomplicated vaginal delivery with epidural anesthesia. Her husband reports that she has been complaining of a progressively worsening, diffuse headache for the past 4 days. She has no prior history of seizures. During her pregnancy, she had diet-controlled gestational diabetes, but her blood pressure was normal. On presentation, she is lethargic and oriented to person only. Her blood pressure is 148/92 mmHg, heart rate is 94/min, and temperature is 37.1°C (98.8°F). Funduscopic examination reveals bilateral papilledema. Neurological examination demonstrates 4/5 motor strength in the right upper and lower extremities. Urine dipstick shows trace protein.

Arrange the following differential diagnoses in order from highest pre-test probability to lowest pre-test probability based on this patient's clinical presentation.

A 42-year-old previously healthy woman arrives at the emergency department reporting the sudden onset of severe, continuous pain in her upper abdomen that radiates directly to her mid-back. She has vomited three times since the pain started four hours ago. She reports no recent alcohol use or new medications. Her temperature is 37.8°C (100.0°F), blood pressure is 135/85 mm Hg, pulse is 110/min, and respiratory rate is 18/min. Examination reveals significant tenderness in the epigastric region with voluntary guarding, but no rebound tenderness or rigidity. Bowel sounds are hypoactive. Which of the following diagnostic studies should be ordered concurrently as part of this patient's initial evaluation? (Select all that apply)

A 34-year-old woman presents to the clinic for evaluation of left calf pain and swelling that began two days ago. Venous duplex ultrasonography confirms a deep vein thrombosis. Her medical history is significant for an unprovoked pulmonary embolism 3 years ago and one pregnancy that ended in fetal demise at 14 weeks gestation. She currently takes no medications. Vital signs are within normal limits.

Laboratory results:

A mixing study is performed, in which the patient's plasma is combined 1:1 with pooled normal plasma. The immediate aPTT of the mixture is $64 \text{ seconds}$, and the aPTT after a 2-hour incubation remains $65 \text{ seconds}$.

Based on the interpretation of these laboratory results, which of the following is the most likely explanation for the patient's prolonged aPTT?

Chronic diarrhea has a broad differential diagnosis, but careful evaluation of extraintestinal manifestations can often lead to a specific etiology. Match each patient's clinical presentation of chronic diarrhea and systemic symptoms with the most likely underlying diagnosis.

A 28-year-old man is brought to the emergency department by emergency medical services after being rescued from a residential house fire. Firefighters report that he was trapped in a closed, smoke-filled bedroom for approximately 10 minutes before being extracted. On arrival, the patient is agitated and speaking in a hoarse voice. He is coughing up dark, carbonaceous sputum. Physical examination reveals partial-thickness burns over his anterior chest and bilateral upper extremities, estimated to involve 18% of his total body surface area. Examination of the face reveals singed nasal hairs, soot in the oropharynx, and mild facial erythema. Lung auscultation demonstrates diffuse bilateral wheezing. Vital signs are: temperature 37.1°C (98.8°F), pulse 122/min, blood pressure 114/72 mm Hg, respiratory rate 26/min, and oxygen saturation 96% on a 15 L/min non-rebreather mask. Which of the following is the most appropriate immediate next step in the management of this patient?

A 68-year-old man comes to the outpatient clinic for a follow-up examination regarding his heart failure. He was diagnosed with New York Heart Association (NYHA) class III heart failure with a reduced ejection fraction (HFrEF) six months ago. An echocardiogram at that time showed a left ventricular ejection fraction of $25\%$. His past medical history is significant for hypertension, type 2 diabetes mellitus, and severe bilateral renal artery stenosis that was diagnosed via magnetic resonance angiography two years ago. His current medications include carvedilol, furosemide, and atorvastatin. The patient reports stable dyspnea on exertion but denies orthopnea, paroxysmal nocturnal dyspnea, or recent weight gain. Vital signs include a blood pressure of $142/86 \text{ mmHg}$ and a regular heart rate of $62 \text{ /min}$. Physical examination reveals a jugular venous pressure of $6 \text{ cm H}_2\text{O}$. The lungs are clear to auscultation bilaterally, and there is no lower extremity edema. Laboratory studies show:

Serum sodium: $138 \text{ mEq/L}$
Serum potassium: $5.6 \text{ mEq/L}$
Blood urea nitrogen: $34 \text{ mg/dL}$
Serum creatinine: $2.2 \text{ mg/dL}$

Which of the following is the most appropriate next step in pharmacologic management to reduce this patient's long-term mortality?

A $34$-year-old man is brought to the emergency department via ambulance after being struck by a high-speed vehicle as a pedestrian. On arrival, he is confused and visibly diaphoretic. His blood pressure is $72/40 \text{ mmHg}$, heart rate is $142 \text{ /min}$, and respiratory rate is $28 \text{ /min}$. Pulse oximetry shows $94\%$ on a non-rebreather mask. The airway is patent, and breath sounds are equal bilaterally. The abdomen is tense and distended. Physical examination reveals an unstable pelvic ring upon gentle medial compression of the iliac crests. Two large-bore peripheral intravenous lines are established, and balanced blood product resuscitation is initiated.

Arrange the following procedural and diagnostic steps in the most appropriate chronological sequence for managing this patient's condition:

A $52$-year-old man is evaluated in the hospital for worsening abdominal pain and new-onset fever. He was admitted $3$ days ago for acute pancreatitis secondary to gallstones. Initial management with aggressive intravenous hydration and analgesics led to transient improvement. Today, his temperature is $39.2^{\circ}\text{C}$ ($102.6^{\circ}\text{F}$), blood pressure is $110/70\text{ mmHg}$, pulse is $115\text{/min}$, and respiratory rate is $20\text{/min}$. Physical examination reveals severe tenderness in the epigastrium with guarding. A contrast-enhanced computed tomography (CT) scan of the abdomen is obtained. The images demonstrate an acute, heterogeneous collection of fluid and necrotic tissue involving the pancreatic body and tail, with multiple small foci of gas noted entirely within the collection. No well-defined capsule is visualized. Which of the following is the most accurate interpretation of these radiologic findings?

A $45$-year-old male is evaluated in the surgical intensive care unit due to worsening respiratory mechanics and hemodynamic instability. He was admitted yesterday after sustaining major trauma in a motor vehicle collision, which necessitated an emergent damage-control laparotomy with perihepatic packing for a severe liver laceration. A temporary abdominal closure device was placed at the conclusion of the surgery. Over the past two hours, the patient's urine output has decreased to $15$ mL/hour. Current vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $80/48$ mm Hg, and a heart rate of $132$/min. The mechanical ventilator is alarming frequently for high peak inspiratory pressures. Physical examination reveals an extremely tense and distended abdomen. Bladder pressure measurement reveals an intra-abdominal pressure of $29$ mm Hg. Which of the following is the most appropriate next step in the management of this patient?

A 46-year-old male patient presents to the internal medicine clinic due to poorly controlled hypertension. His current medication regimen consists of maximally tolerated doses of amlodipine, olmesartan, and chlorthalidone. Today, his resting blood pressure is 168/94 mm Hg. Physical examination is unremarkable with no abdominal bruits, edema, or cushingoid features. Laboratory studies reveal a serum potassium level of 2.8 mEq/L and a serum bicarbonate level of 30 mEq/L. Given the presence of severe hypertension and spontaneous hypokalemia, there is strong suspicion for a specific secondary etiology. The patient's antihypertensive regimen is transitioned to doxazosin and verapamil for several weeks to prevent assay interference, and a stepwise diagnostic evaluation is planned. Arrange the following diagnostic studies in the most appropriate, guideline-directed sequence to evaluate this patient's condition, from the initial diagnostic step to definitive pre-surgical planning.

A $22$-year-old male is transported to the trauma center by police officers following a physical altercation. He sustained a stab wound to the left anterior neck. On arrival, the patient is highly agitated and holding a blood-soaked garment to his neck. Blood is actively oozing from the wound site. His voice is noticeably hoarse, and he is coughing up bright red blood. Vital signs reveal a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $105/65\text{ mmHg}$, pulse of $118/\text{min}$, and respiratory rate of $28/\text{min}$. Oxygen saturation is $89\%$ on room air. Physical examination demonstrates an expanding, pulsatile hematoma on the left side of the neck and audible biphasic stridor. Which of the following is the most appropriate immediate next step in the management of this patient?

A $72$-year-old man is brought to the emergency department from a skilled nursing facility due to altered mental status, fever, and purulent sputum production over the past $24$ hours. His medical history is significant for severe chronic obstructive pulmonary disease (COPD), type $2$ diabetes mellitus, and chronic kidney disease stage $3$. Three weeks ago, he was treated with a $10$-day course of oral levofloxacin for a COPD exacerbation.

On arrival, his temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $122/\text{min}$, and respirations are $28/\text{min}$. Oxygen saturation is $86\%$ on room air.

Physical examination reveals coarse crackles in the right lung base and decreased breath sounds globally.

Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ with $15\%$ bands, blood urea nitrogen of $42\text{ mg/dL}$, and a serum creatinine of $2.1\text{ mg/dL}$ (baseline $1.4\text{ mg/dL}$).

Chest radiograph demonstrates a dense consolidation in the right lower lobe.

After securing the airway and administering a rapid intravenous fluid bolus, vasopressor therapy is initiated.

Which of the following antimicrobial agents should be included in this patient's empiric regimen? (Select all that apply)

Systemic vasculitides often present with overlapping constitutional and organ-specific symptoms, requiring careful differentiation. Match each patient's clinical presentation to the most appropriate formulated differential diagnosis.

A 35-year-old woman with a history of systemic lupus erythematosus (SLE) presents to the emergency department complaining of a 2-hour history of sudden-onset, left-sided pleuritic chest pain and shortness of breath. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mmHg, heart rate is 112/min, respiratory rate is 24/min, and oxygen saturation is 91% on room air. Physical examination is notable for clear lungs bilaterally, a normal cardiac rhythm with no murmurs, and mild, asymmetric edema with tenderness in her left calf.

Based on the clinical presentation, arrange the following differential diagnoses in order from the highest pre-test probability (most likely diagnosis) to the lowest pre-test probability (least likely diagnosis).

A 45-year-old construction worker is brought to the emergency department after a trench collapsed, trapping his right lower extremity under heavy debris for 4 hours. On arrival, he is in significant distress due to excruciating pain in his right calf, which he describes as "10 out of 10." The pain is markedly exacerbated by passive dorsiflexion of his toes. Vital signs show a blood pressure of 135/85 mm Hg, heart rate of 110/min, and respiratory rate of 18/min. Physical examination reveals a tense, swollen right calf with tight, shiny overlying skin. Both dorsalis pedis and posterior tibial pulses are palpable and symmetric to the contralateral side. Capillary refill is 4 seconds in the right foot. A urinary catheter is placed, yielding dark reddish-brown urine. Direct manometry of the right anterior compartment demonstrates a pressure of 45 mm Hg. Based on these findings, which of the following interventions are indicated in the immediate management of this patient? (Select all that apply.)

A 74-year-old woman is brought to the emergency department by her family due to sudden, severe abdominal pain that began 8 hours ago. She has a history of heart failure with reduced ejection fraction and paroxysmal atrial fibrillation. She was previously taking apixaban but discontinued it one month ago after sustaining a traumatic subdural hematoma from a mechanical fall. On arrival, the patient is lethargic and moaning in pain. Her temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $78/48 \text{ mmHg}$, pulse is $132/\text{min}$ and irregularly irregular, and respirations are $24/\text{min}$. Physical examination reveals a distended abdomen that is rigidly tense. There is diffuse rebound tenderness, involuntary guarding, and absent bowel sounds. Laboratory studies show a leukocyte count of $22,000/\mu\text{L}$ and a serum lactate of $7.8 \text{ mmol/L}$. Which of the following is the most appropriate next step in management?

Match each constellation of endocrinologic laboratory findings to the most likely diagnostic etiology in young adult patients presenting with resistant hypertension and unprovoked hypokalemia.

A 42-year-old woman is evaluated in the ambulatory clinic for an 8-month history of progressively worsening exertional dyspnea and fatigue. She has no prior medical conditions, takes no medications, and has never smoked. Vital signs include a blood pressure of 118/76 mmHg, heart rate of 88/min, and respiratory rate of 16/min. Pulse oximetry is 96% on room air.

Cardiovascular examination reveals a regular rate and rhythm, a prominently loud pulmonic component of the second heart sound, and a grade 2/6 holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. The lungs are clear to auscultation bilaterally. There is no jugular venous distention or peripheral edema.

An electrocardiogram demonstrates right axis deviation and right ventricular hypertrophy. A transthoracic echocardiogram reveals an estimated pulmonary artery systolic pressure of 62 mmHg, right ventricular enlargement, and normal left ventricular size and systolic function with no left-sided valvular abnormalities.

Subsequent pulmonary function testing, including spirometry and diffusing capacity of the lungs for carbon monoxide (DLCO), is within normal limits. High-resolution computed tomography of the chest reveals clear lung fields without interstitial lung disease or emphysema.

Which of the following is the most appropriate next step in the diagnostic workup of this patient's condition?

While conducting rounds in the intensive care unit, a physician is urgently called to the bedside of a 72-year-old man who suddenly developed aphasia and right-sided hemiparesis. The patient was admitted five days earlier for the management of a massive saddle pulmonary embolism and has been receiving a continuous intravenous infusion of unfractionated heparin since admission. His medical history includes hypertension, diet-controlled type 2 diabetes, and a mechanical mitral valve replacement performed four years ago.

Vital signs currently show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $110/65\text{ mmHg}$, heart rate of $118/\text{min}$, and respiratory rate of $22/\text{min}$. Physical examination is notable for a new grade 3/6 holosystolic murmur radiating to the axilla. Neurological assessment confirms global aphasia and dense right hemiplegia.

Immediate laboratory analysis reveals:
Leukocyte count: $19,500/\text{mm}^3$
Hemoglobin: $10.4\text{ g/dL}$
Platelet count: $42,000/\text{mm}^3$ (baseline on admission was $215,000/\text{mm}^3$)
Serum creatinine: $2.1\text{ mg/dL}$ (baseline $1.1\text{ mg/dL}$)

An emergent non-contrast CT scan of the head reveals a large acute ischemic infarction in the left middle cerebral artery territory, complicated by scattered petechial hemorrhages. A subsequent bedside transthoracic echocardiogram demonstrates a $1.2\text{ cm}$ highly mobile vegetation attached to the mechanical mitral valve. Blood cultures have been obtained.

Which of the following pharmacologic interventions are appropriate in the immediate management of this patient? (Select all that apply)