All practice questions

A 68-year-old retired architect is brought to the clinic by his husband due to a 14-month history of progressive cognitive changes. The husband reports that the patient frequently misplaces household items, repeats questions in conversation, and recently struggled to complete their annual tax return—a task he previously managed with ease. The patient has a medical history of essential hypertension and hyperlipidemia, both well-controlled on lisinopril and atorvastatin. Vital signs are within normal limits. A complete blood count and comprehensive metabolic panel obtained during a health fair one month ago were completely normal, with no evidence of anemia or electrolyte derangements. Neurological examination shows normal cranial nerves, strength, and reflexes, and his gait is steady. A Montreal Cognitive Assessment (MoCA) is performed, and the patient scores 21/30, losing points primarily on delayed recall and visuospatial tasks. Along with a comprehensive history and physical examination, which of the following tests should be ordered as part of the complete set of initial concurrent diagnostic workup? (Select 3)

A 21-year-old woman is brought to the emergency department by her roommate due to progressive confusion, nausea, vomiting, and ringing in her ears for the past 4 hours. The roommate reports finding several empty bottles of over-the-counter pain relievers in their shared bathroom. On arrival, her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $118/74\text{ mmHg}$, pulse is $122/\text{min}$, and respirations are $28/\text{min}$. Physical examination reveals a diaphoretic, mildly agitated patient. Cardiopulmonary examination is unremarkable except for tachycardia and tachypnea.

Laboratory results are as follows:

Serum chemistry:
Sodium: $141\text{ mEq/L}$
Potassium: $3.2\text{ mEq/L}$
Chloride: $101\text{ mEq/L}$
Bicarbonate: $14\text{ mEq/L}$
BUN: $14\text{ mg/dL}$
Creatinine: $0.9\text{ mg/dL}$
Glucose: $88\text{ mg/dL}$

Arterial blood gas (room air):
pH: $7.45$
pCO2: $19\text{ mmHg}$
pO2: $98\text{ mmHg}$

Serum salicylate level is $65\text{ mg/dL}$ (therapeutic $15-30\text{ mg/dL}$). Acetaminophen level is undetectable.

The physician plans to initiate therapy to enhance the systemic elimination of the ingested toxin. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 52-year-old woman is evaluated in the ambulatory clinic for a routine wellness examination. She reports feeling generally well but mentions experiencing mild, intermittent palpitations over the last three months. She denies heat intolerance, unintentional weight loss, or changes in bowel habits. She has no history of neck radiation or family history of thyroid disease. Her heart rate is $88 \text{ /min}$ and blood pressure is $126/78 \text{ mm Hg}$. On physical examination, a $2.2 \text{ cm}$, firm, mobile, and non-tender nodule is palpated in the right lobe of her thyroid gland. There is no cervical lymphadenopathy. Initial laboratory testing reveals a serum thyroid-stimulating hormone (TSH) level of $0.05 \text{ mU/L}$ (normal: $0.4 - 4.0 \text{ mU/L}$). A subsequent ultrasound of the neck confirms a $2.2 \text{ cm}$ solid, isoechoic nodule in the right thyroid lobe without suspicious sonographic features such as microcalcifications or irregular margins. Which of the following is the most appropriate next step in the diagnostic workup of this patient's nodule?

A 54-year-old man is brought to the emergency department by his wife after he vomited a large amount of bright red blood at home. His medical history is significant for chronic hepatitis C infection and alcohol use disorder. Upon arrival, the patient is lethargic and moans incomprehensibly, opening his eyes only to a sternal rub. Vital signs are temperature 36.2°C (97.2°F), pulse 132/min, blood pressure 78/45 mmHg, respiratory rate 26/min, and oxygen saturation 93% on room air. Physical examination reveals scleral icterus, palmar erythema, and a distended, non-tender abdomen with shifting dullness. Large-bore peripheral intravenous access is obtained, and aggressive volume resuscitation with crystalloids and blood products is initiated. Which of the following is the most appropriate next step in the management of this patient?

A $61$-year-old woman presents to the emergency department with a $1$-day history of sharp right-sided chest pain that worsens with deep inspiration, accompanied by progressive shortness of breath. She has a history of type 2 diabetes mellitus, hypertension, and stage 4 chronic kidney disease. Her current medications include amlodipine, insulin glargine, and atorvastatin. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $138/82\text{ mmHg}$, pulse is $114/\text{min}$, and respirations are $22/\text{min}$. Pulse oximetry shows $92\%$ on room air. BMI is $34\text{ kg/m}^2$. Physical examination is notable for mild swelling and tenderness in the right calf. Laboratory testing shows a serum creatinine of $2.9\text{ mg/dL}$ (baseline $2.7\text{ mg/dL}$) and an estimated creatinine clearance of $17\text{ mL/min}$. Computed tomography pulmonary angiography demonstrates a filling defect in the right lower lobe pulmonary artery. Transthoracic echocardiography reveals normal right ventricular size and function. Which of the following is the most appropriate initial pharmacologic intervention?

A 31-year-old man is brought to the trauma bay by helicopter emergency medical services following a motorcycle crash. He was thrown approximately 30 feet into a ditch. On arrival, he is confused, agitated, and diaphoretic. His airway is intact, and breath sounds are present and equal bilaterally. Vital signs show a temperature of 36.2°C (97.2°F), heart rate of 148/min, blood pressure of 68/38 mm Hg, respiratory rate of 28/min, and oxygen saturation of 95% on 15 L/min of oxygen via a non-rebreather mask. Physical examination reveals extensive ecchymosis over the lower abdomen and perineum, a mechanically unstable pelvis to lateral compression, and a visibly deformed right thigh. Two 16-gauge peripheral intravenous catheters are rapidly established. Which of the following interventions should be ordered simultaneously as the immediate next steps in the patient's stabilization? (Select 3)

A $28$-year-old woman is rushed to the emergency resuscitation bay after collapsing at a local shopping center. Emergency medical technicians report that she was initially responsive but became confused and profoundly lethargic during transport. According to her partner, she had been complaining of escalating, sharp right-sided pelvic pain over the past $24$ hours. Her last menstrual period was approximately eight weeks ago. Upon arrival, her temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $72/40\text{ mmHg}$, heart rate is $142\text{/min}$, and respiratory rate is $24\text{/min}$. Physical examination demonstrates marked pallor, diaphoresis, and a rigid, distended abdomen with diffuse guarding. A rapid point-of-care urine pregnancy test is positive. Bedside focused assessment with sonography for trauma (FAST) reveals a massive amount of free fluid in the hepatorenal recess and the rectouterine pouch. Aggressive intravenous fluid resuscitation with crystalloids and uncrossmatched type O-negative packed red blood cells is immediately initiated through two large-bore peripheral catheters. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old woman is brought to the emergency department by her husband due to severe agitation, confusion, and fever. She has a history of Graves disease but stopped taking her antithyroid medications three months ago. Her temperature is 39.4°C (103.0°F), blood pressure is 158/72 mmHg, and pulse is 152/min and irregular. Physical examination reveals a diffuse, non-tender goiter, marked diaphoresis, and a fine tremor. An electrocardiogram demonstrates atrial fibrillation with rapid ventricular response. A clinical diagnosis of thyroid storm is made. While multiple therapies are required for comprehensive management, they must be administered in a highly specific physiological sequence to prevent the paradoxical worsening of the thyrotoxicosis. Arrange the following pharmacologic interventions in the correct chronological order of administration.

Correlate each distinct thoracic imaging finding with the specific cardiopulmonary pathology it most strongly indicates.

Emergency medical services transport a 42-year-old man to the emergency department for an ongoing seizure. Paramedics report the patient's wife witnessed the onset of generalized tonic-clonic activity 12 minutes prior to arrival. He has a known history of epilepsy and recently missed several doses of his home medications. Upon arrival, the patient remains unresponsive with continuous, rhythmic jerking of all four extremities. Vital signs show a blood pressure of 160/95 mmHg, a heart rate of 132/min, and an oxygen saturation of 94% on a non-rebreather mask. A point-of-care blood glucose level is 115 mg/dL. Intravenous access is rapidly secured. Arrange the following pharmacologic interventions in the correct chronological sequence for the stepwise management of this patient's status epilepticus, starting with the most appropriate immediate therapy and escalating to treatments for refractory and super-refractory cases.

A $78$-year-old woman is brought to the emergency department from a skilled nursing facility due to severe abdominal pain and altered mental status. Staff report that she has had progressive abdominal distention, nausea, and no bowel movements for the past $3$ days. Her past medical history is significant for Parkinson disease, chronic constipation, and moderate Alzheimer dementia. Her temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse is $122/\text{min}$, blood pressure is $85/55\text{ mmHg}$, and respirations are $24/\text{min}$. Physical examination reveals a massively distended abdomen that is diffusely tender to palpation, with severe rigidity and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate level of $4.8\text{ mmol/L}$. An upright abdominal radiograph demonstrates a markedly dilated loop of colon extending from the pelvis to the right upper quadrant in an inverted U-shape, lacking haustra. Which of the following is the most appropriate next step in management?

A 52-year-old man comes to the clinic due to a new-onset tremor and headaches over the past 3 days. He underwent a deceased-donor renal transplantation 8 months ago for end-stage renal disease secondary to hypertensive nephrosclerosis. His maintenance immunosuppression regimen consists of tacrolimus, mycophenolate mofetil, and low-dose prednisone. Two weeks ago, he was diagnosed with esophageal candidiasis by his primary care physician and was started on a 14-day course of oral fluconazole. His temperature is 37.1°C (98.8°F), blood pressure is 168/95 mmHg (baseline 125/80 mmHg), and heart rate is 82/min. Physical examination reveals a fine resting tremor in both hands. The renal allograft is non-tender to palpation.

Laboratory studies show:
Blood urea nitrogen: 42 mg/dL
Serum creatinine: 2.7 mg/dL (baseline 1.3 mg/dL)
Serum potassium: 5.2 mEq/L
Urinalysis: Trace protein, no red blood cells, no white blood cells

Which of the following is the most appropriate next step in the management of this patient?

A 64-year-old woman is evaluated in the surgical intensive care unit for a rapidly declining platelet count. Seven days ago, she underwent a complex coronary artery bypass grafting procedure. Her postoperative course was initially uncomplicated, and she has been receiving subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis. Today, her platelet count is 55,000/μL, representing a 65% drop from her baseline of 180,000/μL. Examination reveals a new, painful, swollen right lower extremity. Venous duplex ultrasonography confirms an acute right popliteal deep vein thrombosis. A clinical diagnosis of heparin-induced thrombocytopenia (HIT) is suspected based on a 4T score of 6 (high probability). Arrange the following management and monitoring steps in the most appropriate chronological sequence for this patient.

A 67-year-old woman is evaluated in the cardiology clinic for a three-month history of episodic chest heaviness. She reports that the discomfort occurs when she performs upper body exertion, such as vacuuming or carrying groceries, and resolves completely after approximately five minutes of rest. Her medical history is significant for type 2 diabetes mellitus, hypertension, hyperlipidemia, advanced bilateral knee osteoarthritis, and severe persistent asthma. She relies on a motorized scooter for mobility due to debilitating joint pain. Her respiratory regimen includes a daily high-dose fluticasone-salmeterol inhaler and oral montelukast, but she still requires albuterol rescue therapy three to four times a week. Vital signs include a blood pressure of $146/88$ mm Hg and a heart rate of $76$/min. Physical examination reveals bilateral end-expiratory wheezes and pronounced crepitus in both knees. The cardiac examination is unremarkable. Her baseline electrocardiogram displays normal sinus rhythm without ischemic changes or conduction delays. Which of the following is the most appropriate next step in diagnostic workup?

A $42$-year-old woman is brought to the emergency department by her husband due to sudden-onset difficulty speaking and weakness in her right arm that began $2$ hours ago. Her medical history includes systemic lupus erythematosus managed with hydroxychloroquine, as well as two spontaneous first-trimester abortions. Vital signs are within normal limits. Neurological examination reveals an expressive aphasia and $2/5$ motor strength in the right upper extremity. A non-contrast head CT demonstrates no acute intracranial hemorrhage. Laboratory studies reveal:

Hemoglobin: $12.1 \text{ g/dL}$
Platelet count: $92,000/\text{mm}^3$
Prothrombin time (PT): $12 \text{ s}$ (Normal: $11-15 \text{ s}$)
Partial thromboplastin time (PTT): $55 \text{ s}$ (Normal: $25-40 \text{ s}$)

A mixing study with normal plasma is performed, and the patient's PTT remains prolonged at $52 \text{ s}$.

Which of the following is the most likely diagnosis?

A 76-year-old woman is admitted to the hospital from the emergency department due to a 3-day history of a productive cough, fever, and worsening shortness of breath. Her past medical history is significant for hypertension, type 2 diabetes mellitus, and major depressive disorder. Her current medications include lisinopril, metformin, and citalopram. She has a documented allergy to amoxicillin, which caused a maculopapular rash on her trunk when she was a teenager; she has never experienced anaphylaxis, wheezing, or lip swelling.

Vital signs include a temperature of $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure of $118/74\text{ mmHg}$, pulse of $102/\text{min}$, and respiratory rate of $26/\text{min}$. Pulse oximetry shows $91\%$ on room air. Physical examination reveals bronchial breath sounds and crackles in the right lower lung field. Laboratory studies show a leukocyte count of $14,500/\mu\text{L}$ with $85\%$ neutrophils. Chest radiograph demonstrates a right lower lobe consolidation. An electrocardiogram obtained on admission shows normal sinus rhythm with a QTc interval of $495\text{ ms}$.

Which of the following is the most appropriate empiric pharmacologic intervention for this patient?

Correlate the following specific clinical risk profiles and functional assessments with their optimal disposition or care transition setting according to standard medical guidelines.

A 48-year-old male presents to the clinic complaining of excessive sweating, diffuse joint pain, and a gradual increase in his shoe size over the past three years. He also mentions that he recently had to have his wedding ring resized because it would no longer fit over his knuckle. On physical examination, his blood pressure is 148/92 mm Hg. He is noted to have coarse facial features, a prominent mandible, macroglossia, and enlarged, doughy hands. The physician strongly suspects an underlying endocrine disorder characterized by hormonal hypersecretion.

Assuming each step confirms the progression of the diagnostic pathway, arrange the following clinical evaluations in the most appropriate sequential order to screen for, confirm, localize, and assess the local complications of this patient's suspected condition.

A 45-year-old man comes to the clinic for a routine follow-up. He has a 5-year history of bipolar I disorder, which has been well-controlled on lithium monotherapy. He has not experienced a manic or depressive episode since starting this medication. Over his last three clinic visits, his blood pressure has been consistently elevated, averaging $154/92$ mm Hg. He has strictly adhered to a low-sodium diet and a regular aerobic exercise program for the past 6 months without significant improvement in his blood pressure. His body mass index is $26$ kg/m $^2$. The remainder of his physical examination is unremarkable. Laboratory studies reveal a serum creatinine of $0.9$ mg/dL and a serum lithium level of $0.8$ mEq/L (therapeutic range: $0.6-1.2$ mEq/L). A decision is made to initiate pharmacologic therapy for his essential hypertension. Which of the following is the most appropriate initial antihypertensive medication for this patient?

An emergency physician evaluates a 62-year-old man who reports three days of progressively worsening left lower abdominal pain accompanied by fever and chills. His medical history is significant for hypertension and hyperlipidemia, both well-controlled with medications. His temperature is 38.7°C (101.7°F), blood pressure is 134/82 mm Hg, pulse is 105/min, and respiratory rate is 16/min. Physical examination demonstrates marked tenderness and guarding over the left lower quadrant, but the abdomen is otherwise soft without diffuse rigidity or generalized rebound tenderness. Laboratory studies show a leukocyte count of 16,500/mm³ with 82% neutrophils. A contrast-enhanced computed tomography scan of the abdomen and pelvis reveals inflammatory changes adjacent to the sigmoid colon, complicated by a well-defined, 5.2-cm unilocular pericolic fluid collection with an enhancing rim. There is no evidence of free intraperitoneal air. Which of the following is the most appropriate next step in the management of this patient?