All practice questions

A 64-year-old woman comes to the clinic due to a 4-month history of frequent, watery, non-bloody diarrhea. She reports having up to 8 loose bowel movements per day, which occasionally wake her from sleep. She has no fever, abdominal pain, nausea, or unintended weight loss. Her past medical history is notable for osteoarthritis, for which she takes daily ibuprofen, and hypertension managed with lisinopril. Vital signs are within normal limits. Abdominal examination is unremarkable. Laboratory studies, including a complete blood count, comprehensive metabolic panel, and thyroid function tests, are normal. Stool studies are negative for infectious etiologies. A colonoscopy reveals an entirely normal-appearing colonic mucosa throughout. Random biopsies are obtained from the right and left colon. Histopathologic examination of the biopsy specimens shows a preserved crypt architecture, an increased number of intraepithelial lymphocytes, chronic inflammation in the lamina propria, and a notably thickened subepithelial eosinophilic band measuring 15 micrometers (normal is typically less than 5 micrometers). Which of the following is the most likely diagnosis based on these histopathologic findings?

Evaluate the following acute clinical presentations. For each patient scenario, identify the single most appropriate diagnostic imaging study to order.

A $38$-year-old woman presents to the clinic with progressive weight gain, facial fullness, and proximal muscle weakness over the past $8$ months. She also reports irregular menstrual periods and easy bruising. Blood pressure is $155/95$ mmHg, and BMI is $32$ kg/m $^2$. Physical examination reveals facial plethora, supraclavicular fat pads, and wide violaceous striae on her abdomen. There is trace peripheral edema. The physician suspects an endogenous endocrine etiology for her symptoms.

Arrange the following diagnostic steps in the most appropriate sequential order for the comprehensive workup of this patient's suspected condition, from initial biochemical screening to final definitive localization.

A 28-year-old woman is brought to the emergency department due to sudden-onset, severe left lower quadrant abdominal pain that started 2 hours ago. She reports associated dizziness, lightheadedness, and mild vaginal spotting. Her last menstrual period was 6 weeks ago. Vital signs show a blood pressure of 88/56 mm Hg, a heart rate of 118/min, and a respiratory rate of 20/min. Physical examination reveals a pale appearing patient with diffuse lower abdominal tenderness, guarding, and rebound tenderness. A bedside urine pregnancy test is positive. A transvaginal ultrasound is immediately performed and demonstrates an empty uterine cavity, a 4-cm complex left adnexal mass, and a large volume of echogenic free fluid in the posterior cul-de-sac. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in management?

Emergency medical services transport a 55-year-old male to the resuscitation bay after he vomited approximately one liter of bright red blood at a local restaurant. The patient's wife notes he has a history of decompensated liver cirrhosis due to chronic alcohol use and has been hospitalized previously for ascites. Upon arrival, the patient is lethargic, responds only to painful stimuli, and is actively coughing up blood clots. Vital signs reveal a temperature of 36.5°C (97.7°F), heart rate of 128/min, blood pressure of 82/45 mm Hg, respiratory rate of 26/min, and oxygen saturation of 91% on room air. Examination shows scleral icterus, spider angiomas on the chest, and a distended, non-tender abdomen. Peripheral intravenous access is established by the nursing staff. Which of the following is the most appropriate immediate next step in management?

A rapid response team is called to the bedside of a 45-year-old hospitalized man who developed sudden-onset respiratory distress. The patient was admitted yesterday for community-acquired pneumonia and was receiving his second dose of intravenous piperacillin-tazobactam. Ten minutes into the infusion, he began complaining of severe throat tightness, shortness of breath, and feeling dizzy. The bedside nurse immediately stopped the antibiotic infusion and applied supplemental oxygen via a non-rebreather mask.

Vital signs reveal a blood pressure of 78/42 mm Hg, a heart rate of 138/min, a respiratory rate of 28/min, and an oxygen saturation of 91% on the non-rebreather mask. Physical examination shows diffuse urticaria over the trunk and extremities, periorbital edema, and audible inspiratory stridor with widespread expiratory wheezing.

Which of the following are the most appropriate immediate next steps in the management of this patient? (Select exactly 2 options)

Match each classic radiographic finding with the most likely rheumatologic or joint disorder it represents.

A 29-year-old woman, G2P1, at 24 weeks gestation presents to the emergency department with sudden-onset shortness of breath and right-sided pleuritic chest pain. Her heart rate is 112/min, respiratory rate is 22/min, blood pressure is 110/70 mmHg, and oxygen saturation is 94% on room air. Physical examination reveals clear lungs bilaterally, normal heart sounds, and no asymmetric lower extremity edema, erythema, or tenderness. An electrocardiogram shows sinus tachycardia. You are planning the diagnostic pathway to evaluate for a suspected pulmonary embolism while minimizing fetal and maternal radiation exposure.

Arrange the following diagnostic modalities in the correct sequential order as recommended by current clinical guidelines, proceeding to the next step only if the preceding test is negative, normal, or non-diagnostic.

Match each acute clinical presentation with the most appropriate and urgent next diagnostic step.

A 26-year-old woman is brought to the emergency department by paramedics after being found unresponsive in her apartment. Her roommate reports finding empty bottles of amitriptyline and diphenhydramine on her nightstand. En route to the hospital, the patient had a 3-minute generalized tonic-clonic seizure. Upon arrival, she is actively seizing. Vital signs are temperature 38.2°C (100.8°F), blood pressure 82/50 mm Hg, pulse 138/min, and respirations 8/min. Pulse oximetry shows 88% on room air. Pupils are 7 mm bilaterally and sluggishly reactive. Mucous membranes are dry. An immediate electrocardiogram reveals sinus tachycardia with a QRS duration of 165 msec and a prominent terminal R wave in lead aVR. Which of the following are the most appropriate immediate simultaneous steps in the stabilization of this patient? (Select 3)

Review the following complex clinical presentations. Match each patient scenario with the single most appropriate next imaging modality required to localize pathology, stage disease, or guide definitive management.

A 52-year-old man presents to the clinic with a 2-year history of progressive, severe proximal muscle weakness, deep bone pain, and multiple atraumatic rib fractures. Laboratory evaluation reveals the following:

A whole-body somatostatin receptor PET/CT scan demonstrates an intensely avid, 2.5-cm soft tissue mass in the plantar aspect of his left foot. The patient undergoes a wide local excision of the lesion.

Which of the following pathologic and immunohistochemical findings are characteristic of this patient's most likely diagnosis? (Select all that apply)

A 25-year-old woman presents to the clinic with a 3-day history of dysuria, urinary frequency, and suprapubic discomfort. She is sexually active with a new partner. Vital signs are normal, and she is afebrile. Physical examination reveals mild suprapubic tenderness but no costovertebral angle (CVA) tenderness. Arrange the following differential diagnoses in order from the most likely (highest pre-test probability) to the least likely for this patient's acute presentation.

A 64-year-old man with a history of poorly controlled hypertension presents to the emergency department with sudden-onset, severe, tearing pain between his shoulder blades that began 2 hours ago. He appears in severe distress. Blood pressure is 195/110 mmHg and heart rate is 108/min. The pulses are equal in all four extremities. An electrocardiogram is unremarkable. A non-contrast computed tomography (CT) scan of the chest reveals a crescent-shaped, high-attenuation area within the wall of the descending thoracic aorta, extending from just distal to the left subclavian artery down to the diaphragmatic hiatus. Subsequent CT angiography shows no intimal flap, no double lumen, and no contrast extravasation into the aortic wall. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in management?

During morning rounds, the nephrology service evaluates a newly admitted patient presenting with severe anasarca and new-onset renal dysfunction. The patient, a $58$-year-old individual with a history of hypertension, reports noticing persistently frothy urine for the past $12$ weeks. Vital signs show a blood pressure of $152/94 \text{ mmHg}$. Laboratory studies demonstrate a serum creatinine of $1.8 \text{ mg/dL}$ and a serum albumin level of $2.5 \text{ g/dL}$. Urinalysis reveals $4+$ proteinuria with microscopic hematuria, and a $24$-hour urine collection confirms the presence of $5.2 \text{ g}$ of protein. A percutaneous renal biopsy is obtained. Light microscopy reveals prominent mesangial expansion and capillary wall thickening. Congo red staining demonstrates no evidence of apple-green birefringence under polarized light. Electron microscopy reveals dense deposits composed of randomly oriented, non-branching fibrils measuring $18 \text{ nm}$ to $22 \text{ nm}$ in diameter located within the mesangium and glomerular basement membranes. Immunohistochemical staining of the biopsy tissue shows strong positivity for DNAJB9. Based on these histopathologic and molecular findings, which of the following is the most likely diagnosis?

A 44-year-old woman comes to the emergency department due to a 3-hour history of severe, unrelenting pain in the right upper quadrant of her abdomen. She says the pain started shortly after she ate a high-fat meal for lunch. The pain radiates to her right shoulder, and she reports one episode of vomiting. She has experienced similar, milder episodes in the past that resolved on their own. Her temperature is 37.9°C (100.2°F), blood pressure is 132/86 mmHg, heart rate is 98/min, and respiratory rate is 16/min. On physical examination, the patient winces and abruptly halts her inspiration when the physician deeply palpates the right upper quadrant. Laboratory studies show a leukocyte count of 12,500/mm³ and normal serum liver aminotransferases, total bilirubin, and lipase levels. Which of the following is the most appropriate initial imaging study to establish the diagnosis?

A university student is rushed to the resuscitation bay after being discovered seizing in a dormitory. Scattered empty bottles of amitriptyline and diphenhydramine were located nearby. The patient is currently exhibiting continuous generalized tonic-clonic movements. Physical examination reveals flushed, dry skin and symmetrically dilated pupils. Continuous monitoring displays a pulse of 142/min, blood pressure of 76/40 mm Hg, and oxygen saturation of 92% on room air. An electrocardiogram rhythm strip shows a wide-complex sinus tachycardia with a QRS duration of $165$ msec and a prominent terminal R wave in lead aVR.

Which of the following are the MOST appropriate simultaneous initial stabilization steps? (Select 2)

A 32-year-old woman is evaluated in the emergency department for sudden-onset shortness of breath and right-sided pleuritic chest pain that began 2 hours ago. She has a history of an unprovoked deep vein thrombosis 3 years ago, for which she completed a 6-month course of anticoagulation. Her only current medication is an oral contraceptive pill. Two years ago, she underwent a computed tomography (CT) scan of the abdomen with intravenous contrast for suspected appendicitis and developed severe anaphylaxis requiring intubation. Her temperature is 37.1°C (98.8°F), blood pressure is 114/72 mmHg, heart rate is 118/min, and respiratory rate is 24/min. Pulse oximetry shows 92% on room air. Physical examination reveals clear breath sounds bilaterally and normal heart sounds. The lower extremities are symmetric with no edema, erythema, or tenderness. An electrocardiogram demonstrates sinus tachycardia. A chest radiograph is unremarkable.

Which of the following is the most appropriate next imaging study to order for this patient?

A 55-year-old man presents to the emergency department with acute onset of severe, tearing back pain. His blood pressure is 190/110 mm Hg, and his heart rate is 105/min. An electrocardiogram shows normal sinus rhythm without ischemic changes. Computed tomography (CT) angiography of the chest and abdomen reveals an intimal flap that originates just distal to the left subclavian artery and extends into the descending thoracic aorta. The ascending aorta and aortic arch are completely unremarkable. There is no imaging evidence of bowel ischemia, and renal perfusion appears intact. Based on these specific imaging findings, which of the following is the most appropriate initial step in management?

A 45-year-old woman presents to the clinic with a 6-month history of progressive shortness of breath on exertion. She has no significant past medical history and takes no medications. Vital signs are within normal limits, with an oxygen saturation of 96% on room air. Physical examination reveals a loud pulmonic component of the second heart sound (P2), a right-sided S3 gallop, and trace bilateral lower extremity edema. Lungs are clear to auscultation bilaterally. Electrocardiography demonstrates right axis deviation and right ventricular hypertrophy. The physician suspects pulmonary hypertension and plans a stepwise diagnostic evaluation to confirm the diagnosis and determine the specific etiology.

Arrange the following diagnostic modalities in the correct sequential order for the comprehensive workup of this patient's suspected pulmonary hypertension, from the most appropriate initial evaluation to definitive hemodynamic confirmation.