All practice questions

During morning rounds on the cardiology service, a physician evaluates an 82-year-old patient who was admitted overnight for recurrent syncope secondary to critical aortic stenosis. The patient has a past medical history of mild Alzheimer dementia and currently scores 24/30 on the Mini-Mental State Examination. When discussing treatment options, the patient states, "The emergency doctor explained that without a new valve, my heart will stop. I understand that perfectly. However, I have lived a full life and want to let nature take its course without any operations." The patient accurately repeats the details of the proposed transcatheter aortic valve replacement, including the procedural risks and the high likelihood of mortality if left untreated.

Later that afternoon, the patient's eldest son arrives with a valid Durable Power of Attorney for Healthcare document naming him as the primary agent. He states, "My mother has dementia and cannot make these decisions anymore. I am authorizing the valve replacement immediately; please proceed."

Which of the following is the most appropriate action by the physician?

A 78-year-old man is brought to the emergency department after suffering a massive intracerebral hemorrhage. He is currently comatose and requires mechanical ventilation. The neurology team determines that he has suffered irreversible brain damage and lacks medical decision-making capacity. The patient's eldest son, who lives out of state, arrives at the hospital and presents a document establishing him as the patient's financial power of attorney. He insists that all life-sustaining measures be continued indefinitely. Shortly after, the patient's close friend arrives and presents a valid, legally executed durable power of attorney for healthcare naming him as the patient's healthcare proxy. The friend states that the patient had explicitly told him he would never want to be kept alive on a ventilator in a comatose state, and requests compassionate extubation. Which of the following is the most appropriate action by the physician?

A 5-year-old boy is brought to the emergency department with status epilepticus. The attending physician verbally orders an intravenous loading dose of phenytoin. The administering nurse calculates the requested dose based on the patient's weight and realizes it is ten times the recommended maximum, which could be fatal. The nurse politely brings this discrepancy to the physician's attention, but the physician appears distracted by another critically ill patient and quickly replies, 'I know what I am doing, just give the dose I ordered.' Which of the following is the most appropriate immediate next action for the nurse?

A 66-year-old woman presents to the clinic with a 3-month history of frequent, watery, nonbloody diarrhea. She reports 5 to 7 loose bowel movements per day, sometimes awakening her at night. She has a medical history of osteoarthritis and depression, for which she takes celecoxib and sertraline. Vital signs are within normal limits, and physical examination of the abdomen is unremarkable. Laboratory tests, including a complete blood count, comprehensive metabolic panel, and thyroid-stimulating hormone, are normal. Stool studies are negative for ova and parasites, and a stool culture yields normal flora. A colonoscopy is performed, which reveals a structurally intact, normal-appearing mucosal surface from the rectum to the cecum. Random colonic biopsies are obtained. Histologic examination demonstrates a thickened, subepithelial, eosinophilic, acellular band measuring 20 micrometers in depth. The surface epithelium is intact but infiltrated by an increased number of intraepithelial lymphocytes. The crypt architecture is completely normal, with no evidence of cryptitis or crypt abscesses. Based on the clinical presentation and histopathologic findings, which of the following is the most likely diagnosis?

A 22-year-old male college student comes to the university health clinic complaining of a sharp pain in his left chest that began abruptly while he was sitting in class 2 hours ago. He reports mild shortness of breath but denies cough, fever, or trauma. He is tall and thin. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 98/min, and respirations 18/min. Pulse oximetry shows 97% on room air. Lung auscultation reveals diminished breath sounds over the left upper lung field. A chest radiograph is performed and demonstrates a thin, sharply defined white line running parallel to the left chest wall, with a complete absence of vascular markings distal to this line. There is no tracheal deviation or mediastinal shift.

Based on the radiographic findings described, which of the following is the most likely diagnosis?

A 38-year-old woman comes to the clinic for evaluation of an incidental liver mass. Two weeks ago, she underwent a right upper quadrant abdominal ultrasound for biliary colic, which revealed cholelithiasis and a 4.5-cm solid mass in the right hepatic lobe. Her abdominal pain has completely resolved since that time. She takes a daily combined oral contraceptive pill, which she has used for the past 10 years. She drinks alcohol socially and does not use tobacco. Her vital signs and physical examination are unremarkable. Laboratory studies, including a complete blood count, comprehensive metabolic panel, and alpha-fetoprotein, are all within normal limits. A multiphasic contrast-enhanced CT scan of the abdomen is performed to further characterize the mass. The imaging reveals a well-demarcated 4.5-cm lesion in the right lobe of the liver. During the arterial phase, the lesion demonstrates early peripheral, nodular contrast enhancement. During the portal venous and delayed phases, there is progressive, centripetal fill-in of the contrast material. Based on the interpretation of these imaging results, which of the following is the most appropriate next step in management?

A 54-year-old man presents for a routine follow-up 9 months after receiving a deceased-donor renal allograft. His post-transplant course was initially uncomplicated. His current immunosuppressive regimen includes tacrolimus, mycophenolate mofetil, and prednisone. Over the past six weeks, his serum creatinine has steadily increased from a baseline of $1.3$ mg/dL to $2.7$ mg/dL. He reports no fever, dysuria, or gross hematuria. Vital signs are within normal limits. Trough tacrolimus level is $7.5$ ng/mL (target: $5-8$ ng/mL). Urinalysis shows trace protein and $2-4$ WBCs/hpf, with no RBCs or casts. A renal allograft biopsy is performed, and the pathology report is as follows:

Microscopic Description:
- Glomeruli: 18 glomeruli present, 1 globally sclerosed. The remaining glomeruli demonstrate normocellular tufts with patent capillary loops. No crescents or transplant glomerulopathy are identified.
- Tubules and Interstitium: Patchy mononuclear inflammatory infiltrates involve approximately $40\%$ of the sampled cortex. Focally, multiple tubular cross-sections show lymphocytes crossing the tubular basement membrane, with up to 6 lymphocytes per tubular cross-section. Scattered tubular epithelial cells exhibit markedly enlarged nuclei containing homogenous, basophilic, ground-glass intranuclear inclusions that compress host chromatin against the nuclear membrane. No intracytoplasmic inclusions are seen. Isometric vacuolization of the proximal tubular cytoplasm is absent.
- Vessels: Small arteries and arterioles demonstrate mild intimal fibroplasia. No significant nodular arteriolar hyalinosis or endothelialitis is observed.
- Immunofluorescence: Staining for IgG, IgA, IgM, C3, and C1q is negative in the glomeruli. Peritubular capillaries are negative for C4d deposition.

Based on the histopathologic interpretation of this biopsy, which of the following is the most likely diagnosis?

A 45-year-old man presents to the clinic for the evaluation of progressive lower extremity swelling over the past three weeks. He has no significant past medical history and takes no medications. Vital signs are within normal limits. Physical examination demonstrates marked bilateral pitting edema extending to the knees. Laboratory evaluation reveals a serum albumin level of 2.2 g/dL and a serum creatinine of 0.8 mg/dL. Urinalysis demonstrates 4+ proteinuria with no hematuria or cellular casts. A 24-hour urine collection confirms 6.8 g of protein. A percutaneous renal biopsy is performed to establish the diagnosis. Light microscopy shows uniform, diffuse thickening of the glomerular capillary walls without an increase in cellularity. Jones methenamine silver staining highlights projections of basement membrane material, creating a "spike and dome" appearance. Immunofluorescence demonstrates a diffuse granular pattern of IgG and C3 deposition along the capillary loops. Which of the following is the most likely diagnosis?

A nephrologist is reviewing renal biopsy reports for four different adult patients who presented with various nephritic or nephrotic syndromes. To establish the correct diagnosis, match each specific glomerular disease with its most pathognomonic histological, immunofluorescence, or ultrastructural finding on renal biopsy.

Match each classic radiographic imaging finding (sign) with its most likely associated clinical condition.

A rapid response team is activated for a 73-year-old woman who collapsed on the orthopedic ward. She is on postoperative day 8 following a right total hip arthroplasty. Upon arrival, the patient is profoundly lethargic, responding only to painful stimuli with incomprehensible groans. She is severely diaphoretic and has mottled extremities. Vital signs are temperature 37.6°C (99.7°F), blood pressure 62/40 mm Hg, heart rate 138/min, and respiratory rate 36/min. Pulse oximetry is 83% despite receiving 15 L/min of oxygen via a non-rebreather mask. Physical examination reveals jugular venous distention up to the angle of the mandible. Lung auscultation is clear bilaterally. Bedside point-of-care ultrasound demonstrates a massively dilated right ventricle with apical sparing, paradoxical motion of the interventricular septum into the left ventricle during systole, and an underfilled left ventricle. No pericardial effusion is present. The team prepares to intervene. Which of the following is the most appropriate immediate next step in the stabilization of this patient?

An unresponsive 72-year-old male with known severe chronic obstructive pulmonary disease arrives at the triage area via ambulance. His wife, who accompanied him, reports a 24-hour history of escalating breathlessness culminating in extreme lethargy this morning. Vital signs obtained immediately upon transfer to the resuscitation bay demonstrate a temperature of 37.1°C (98.8°F), blood pressure of 158/92 mm Hg, heart rate of 118/min, and a respiratory rate of 8/min characterized by shallow excursions. Pulse oximetry indicates an oxygen saturation of 81% on room air. The patient only withdraws from painful stimuli and cannot answer questions. Chest auscultation reveals globally decreased air entry and faint expiratory wheezing. Which of the following represents the single most urgent initial step in this patient's clinical management?

A 32-year-old male construction worker is brought to the trauma bay after falling approximately 20 feet from scaffolding. He is moaning incomprehensibly and has blood pooling in his oropharynx with prominent gurgling sounds on inspiration. His blood pressure is 85/50 mm Hg and heart rate is 135/min. Arrange the following initial evaluation and stabilization steps in the correct chronological sequence according to standard trauma life support principles.

A 29-year-old male industrial worker is rushed to the trauma bay following extraction from a closed-space chemical fire. On arrival, he is conscious but agitated. His voice is noticeably hoarse, and he has a harsh, brassy cough. Physical examination reveals singed facial hair, carbonaceous deposits in the posterior oropharynx, and partial-thickness burns covering his anterior chest and bilateral upper extremities. Vital signs show a heart rate of 128/min, blood pressure of 115/75 mmHg, and respiratory rate of 30/min. Pulse oximetry displays 99% while receiving 100% oxygen via a non-rebreather mask. Which of the following is the most appropriate initial step in the management of this patient?

A 54-year-old woman is evaluated in the outpatient pulmonary clinic for a 6-month history of progressive shortness of breath with exertion. She reports no chest pain, orthopnea, or syncope. She has a history of unprovoked deep vein thrombosis 3 years ago, for which she completed 6 months of anticoagulation therapy. Her current medications include a daily multivitamin. Vitals show a blood pressure of $128/82$ mm Hg, pulse of $88$/min, and respiratory rate of $18$/min. Pulse oximetry is $96\%$ on room air. Physical examination reveals clear lung fields bilaterally. Cardiac examination demonstrates a parasternal heave and a prominently split $S_2$ with a loud pulmonic component. Transthoracic echocardiography reveals right atrial and right ventricular enlargement, flattened interventricular septum during systole, and an estimated right ventricular systolic pressure of $65$ mm Hg. Left ventricular ejection fraction is $60\%$ with normal diastolic function. Which of the following is the most appropriate next step in the diagnostic workup of this patient?

A 45-year-old man comes to the emergency department due to the sudden onset of severe, colicky right flank pain that radiates to his right groin. He states the pain began 2 hours ago and is 10/10 in intensity. He is pacing around the examination room and cannot find a comfortable position. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 145/90 mmHg, heart rate of 98/min, and respiratory rate of 18/min. Physical examination reveals right costovertebral angle tenderness, but the abdomen is soft and non-tender without rebound or guarding. Urinalysis demonstrates 30-50 red blood cells/hpf and no leukocyte esterase or nitrites. Which of the following is the most appropriate next step in the diagnostic evaluation for this patient?

A $48$-year-old African American man presents with a $3$-week history of progressive lower extremity edema, facial swelling, and frothy urine. He has a history of well-controlled hypertension. Vital signs show a blood pressure of $142/88$ mmHg. Laboratory studies reveal a serum creatinine of $1.4$ mg/dL, serum albumin of $2.1$ g/dL, and a $24$-hour urine protein excretion of $7.2$ g. Serologic workup for HIV, hepatitis B, and hepatitis C is negative. A percutaneous renal biopsy is performed, yielding a core of tissue containing $12$ glomeruli. Light microscopy reveals normal glomerular architecture with thin capillary walls and no evidence of segmental sclerosis, crescent formation, or hypercellularity. Immunofluorescence is negative for all immunoglobulins and complement components. Electron microscopy demonstrates extensive, diffuse effacement of podocyte foot processes with no electron-dense deposits. The synoptic pathology report explicitly notes that the biopsy specimen consists entirely of superficial cortical tissue and completely lacks juxtamedullary glomeruli. Based on these specific biopsy limitations, which of the following pathologic diagnoses is at the highest risk of being erroneously excluded due to a sampling artifact?

A 58-year-old woman presents to the emergency department complaining of left lower quadrant abdominal pain that has progressively worsened over the past 48 hours. She reports associated nausea, decreased appetite, and a subjective fever. She has a history of hyperlipidemia and chronic constipation but no previous episodes of similar abdominal pain. Her temperature is 38.3°C (100.9°F), blood pressure is 128/78 mmHg, pulse is 90/min, and respirations are 16/min. Abdominal examination demonstrates focal tenderness to palpation in the left lower quadrant with voluntary guarding, but no rebound tenderness or rigidity. Bowel sounds are hypoactive. Laboratory evaluation reveals a leukocyte count of 14,500/mm³. Which of the following is the most appropriate initial diagnostic study for this patient?

Match each distinct pathognomonic neuroimaging finding on computed tomography (CT) or magnetic resonance imaging (MRI) with its corresponding acute neurologic condition.

A 78-year-old woman is brought to the emergency department by her family due to the sudden onset of severe, relentless abdominal pain that began 2 hours ago. She also reports one episode of non-bloody emesis. Her past medical history is significant for hypertension, type 2 diabetes mellitus, and atrial fibrillation. She was prescribed apixaban but admits she stopped taking it two weeks ago due to financial difficulties. Current vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 145/85 mm Hg, pulse of 118/min and irregularly irregular, and respiratory rate of 22/min. Physical examination reveals a soft, non-distended abdomen. There is mild, diffuse tenderness to palpation, but no guarding, rebound tenderness, or rigidity. Bowel sounds are diminished. Stool guaiac test is negative. Given the most likely diagnosis, which of the following studies represent the most appropriate initial concurrent diagnostic workup for this patient? (Select all that apply)