All practice questions

A 28-year-old woman comes to the clinic reporting a 3-day history of unprovoked nosebleeds and a new rash on her legs. She reports having a mild viral upper respiratory infection two weeks ago but otherwise feels well. She takes no medications and has no family history of bleeding disorders. Her vital signs are within normal limits. Physical examination reveals scattered, pinpoint, red, non-blanching macules on her bilateral lower extremities. There is no lymphadenopathy or hepatosplenomegaly. Laboratory evaluation reveals:

Hemoglobin: 13.2 g/dL
Leukocyte count: 7,200/mm³
Platelet count: 18,000/mm³
Prothrombin time (PT): 12 seconds
Partial thromboplastin time (PTT): 28 seconds

Based on the clinical presentation and laboratory findings, which of the following is the most likely diagnosis?

A 65-year-old man presents to the pulmonology clinic for evaluation of progressive dyspnea on exertion and a dry cough that has worsened over the last year. He has a 30-pack-year smoking history but quit 5 years ago. Auscultation of the lungs reveals bibasilar end-inspiratory 'Velcro-like' crackles. Pulmonary function tests show a restrictive pattern with decreased diffusion capacity for carbon monoxide (DLCO). High-resolution computed tomography (HRCT) of the chest reveals peripheral reticular opacities and traction bronchiectasis, but the presence of honeycombing is equivocal. Due to the indeterminate HRCT pattern, a video-assisted thoracoscopic surgery (VATS) lung biopsy is performed.

The synoptic pathology report describes a patchy, heterogeneous fibrosing process. At low power, areas of dense collagenous fibrosis alternate with zones of relatively normal lung parenchyma. The fibrosis is primarily subpleural and paraseptal. High-power examination reveals discrete aggregates of proliferating fibroblasts and myofibroblasts (fibroblastic foci) at the interface between the dense scars and normal lung. There are no well-formed granulomas, eosinophilic infiltrates, or prominent intra-alveolar organizing exudates.

Based on the integration of the patient's clinical presentation and the histopathologic findings from the lung biopsy, which of the following is the most likely diagnosis?

Emergency medical services bring a 33-year-old male construction worker to the trauma bay after he fell approximately 6 meters (20 feet) from a scaffold. The prehospital crew reports that he has been progressively struggling to breathe during transport. According to a coworker who accompanied him, the patient has a past medical history of asthma and uses an albuterol inhaler occasionally. On arrival, the patient is highly agitated, diaphoretic, and gasping for air. Vital signs include a temperature of 36.8°C (98.2°F), heart rate of 142/min, blood pressure of 74/42 mm Hg, respiratory rate of 36/min, and oxygen saturation of 86% despite receiving oxygen via a non-rebreather mask. Physical examination reveals distended jugular veins and a trachea that is palpably shifted toward the right side. Auscultation demonstrates completely absent breath sounds over the entire left lung field. The abdomen is non-distended, and the pelvis is clinically stable. Two large-bore peripheral intravenous lines have been established. Which of the following is the most appropriate immediate next step in the management of this patient?

A 52-year-old woman is brought to the emergency department by emergency medical services after the sudden onset of a severe headache while lifting a heavy box. She describes the pain as "the worst headache of my entire life." The pain is diffuse and accompanied by severe nausea, one episode of vomiting, and sensitivity to light. Her medical history is significant for essential hypertension and tobacco use. Her temperature is 37.1°C (98.8°F), blood pressure is 182/105 mmHg, pulse is 98/min, and respirations are 18/min. On physical examination, the patient appears uncomfortable and keeps her eyes closed. There is mild resistance to passive neck flexion. Neurological examination is otherwise unremarkable with no focal motor or sensory deficits. Which of the following is the single most appropriate initial imaging study for this patient?

A 24-year-old G1P0 woman at 26 weeks gestation presents to the emergency department with severe, colicky right flank pain radiating to the right labia, accompanied by nausea and microscopic hematuria. She is afebrile, and her vital signs are within normal limits. Physical examination reveals exquisite right costovertebral angle tenderness. The clinical presentation is highly suspicious for nephrolithiasis.

Arrange the following diagnostic imaging modalities in the correct sequential order of utilization for evaluating suspected nephrolithiasis in this pregnant patient, proceeding from the most appropriate initial test to the definitive test of last resort.

A 34-year-old woman is evaluated in the gastroenterology outpatient clinic for a 6-month history of chronic, non-bloody, voluminous diarrhea and a 4-kg (8.8-lb) weight loss. She also reports severe, generalized fatigue. On physical examination, her vital signs are within normal limits. Skin examination reveals an intensely pruritic, papulovesicular eruption symmetrically distributed over her extensor surfaces, particularly the elbows, knees, and buttocks. Laboratory studies demonstrate a microcytic anemia with a remarkably low serum ferritin level. The physician strongly suspects an underlying immune-mediated gastrointestinal disorder and performs an esophagogastroduodenoscopy with multiple biopsies from the distal duodenum. Which of the following histopathologic findings are characteristic of this patient's underlying condition and would most likely be observed on the biopsy specimen? (Select all that apply)

Evaluate the following classic patient presentations. Match each clinical scenario with the most appropriate single initial diagnostic imaging modality required to establish the diagnosis.

Match each distinct pathognomonic finding on brain magnetic resonance imaging (MRI) with its corresponding neurological condition.

A 68-year-old man presents to the outpatient clinic with a 3-week history of progressive jaundice, dark urine, and pale stools. He notes a 6.8-kg (15-lb) unintentional weight loss over the last two months but denies abdominal pain, fever, or chills. He has a 40-pack-year smoking history. Physical examination is notable for profound scleral icterus and a palpable, smooth, non-tender mass in the right upper quadrant. Laboratory studies demonstrate a total bilirubin of 9.2 mg/dL, direct bilirubin of 7.1 mg/dL, and an alkaline phosphatase of 510 U/L. The clinical team suspects a malignant etiology for the patient's presentation and initiates a stepwise diagnostic evaluation.

Arrange the following imaging modalities in the most appropriate chronological sequence for evaluating this patient, from initial investigation to definitive local staging and tissue sampling.

During a multidisciplinary gastrointestinal tumor board, the team reviews the pathology of a 15-mm sessile mucosal elevation completely excised from the right colon of a 48-year-old patient. The pathologist's report describes a mucosal proliferation characterized by a prominent saw-toothed, serrated architecture extending deep into the crypt bases. The crypt bases are notably dilated, often displaying a horizontal, 'L-shaped' or 'boot-like' growth pattern along the muscularis mucosae. Conventional nuclear stratification and elongation (cytologic dysplasia) are absent. Ancillary molecular testing of the lesional tissue demonstrates a $BRAF$ V600E mutation and high microsatellite instability (MSI-H) due to $MLH1$ promoter hypermethylation.

Based on these histopathological and molecular findings, which of the following is the most accurate diagnostic interpretation?

A 68-year-old man is brought to the emergency department complaining of a sudden onset of excruciating, tearing pain in his chest that radiates directly to his back. The pain began 45 minutes ago while he was eating dinner. His medical history is significant for long-standing hypertension, type 2 diabetes mellitus, and stage 4 chronic kidney disease with a baseline serum creatinine of 2.6 mg/dL. His current medications include amlodipine, lisinopril, aspirin, and insulin. On physical examination, he appears in severe distress and is diaphoretic. His blood pressure is 185/105 mmHg in the right arm and 140/90 mmHg in the left arm. His heart rate is 105/min. Cardiac auscultation reveals a faint, decrescendo diastolic murmur at the right upper sternal border. The lungs are clear to auscultation bilaterally. Neurologic examination is unremarkable. An electrocardiogram shows sinus tachycardia with voltage criteria for left ventricular hypertrophy, but no acute ST-segment or T-wave abnormalities. A portable chest radiograph demonstrates a widened mediastinum. Laboratory studies reveal a current serum creatinine of 2.9 mg/dL. Which of the following is the most appropriate next step in the diagnostic workup?

A 26-year-old woman comes to the clinic after noticing a small lump in her left breast while showering two days ago. She has no significant past medical history and takes no medications. There is no family history of breast or ovarian cancer. Vital signs are within normal limits. Physical examination reveals a $2$-cm, firm, mobile, well-circumscribed mass in the upper outer quadrant of the left breast. There are no skin changes, nipple retraction, or axillary lymphadenopathy. Which of the following is the most appropriate next step in the diagnostic workup?

A $74$-year-old man is brought to the emergency department due to the sudden onset of severe, diffuse abdominal pain that began $2$ hours ago. He reports nausea and one episode of non-bloody, non-bilious emesis. His medical history is significant for hypertension, type 2 diabetes mellitus, chronic kidney disease with a baseline serum creatinine of $1.7\text{ mg/dL}$, and paroxysmal atrial fibrillation. He was prescribed apixaban but admits to missing multiple doses over the past week. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $145/88\text{ mm Hg}$, pulse is $118/\text{min}$ and irregularly irregular, and respirations are $22/\text{min}$. Pulse oximetry shows $96\%$ on room air. Physical examination reveals a patient in visible distress, writhing in pain on the stretcher. However, abdominal examination shows a soft, non-distended abdomen with only mild diffuse tenderness to deep palpation; there is no rebound, guarding, or rigidity. Bowel sounds are decreased. Laboratory studies show:

Leukocyte count: $18,500/\text{mm}^3$
Hemoglobin: $14.2\text{ g/dL}$
Platelet count: $210,000/\text{mm}^3$
Serum creatinine: $2.9\text{ mg/dL}$
Blood urea nitrogen: $48\text{ mg/dL}$
Serum lactate: $4.8\text{ mmol/L}$

Which of the following is the most appropriate next step in diagnostic imaging for this patient?

A 54-year-old man is brought to the emergency department by his partner after vomiting a large amount of bright red blood at home. He has a known history of alcohol use disorder and cirrhosis. On arrival, he is lethargic and visibly pale. Vital signs reveal a heart rate of 134/min, a blood pressure of 78/46 mm Hg, a respiratory rate of 22/min, and an oxygen saturation of 96% on ambient air. His abdomen is distended but non-tender. Which of the following is the most appropriate initial step in the stabilization of this patient?

A clinician is evaluating several patients presenting to the urgent care clinic with a primary complaint of a 'red eye'. Match each of the following classic ocular presentations with its most likely primary differential diagnosis.

A 48-year-old woman is brought to the emergency department by her husband after the sudden onset of the 'worst headache of my life.' The headache began 2 hours ago while she was lifting a heavy box. She reports severe photophobia and has vomited twice since the onset. Her current temperature is 37.1 °C (98.8 °F), blood pressure is 165/95 mm Hg, and pulse is 92/min. Neurological examination reveals nuchal rigidity but is otherwise non-focal. Arrange the following imaging modalities in the most appropriate chronological sequence for the initial diagnosis, vascular characterization, and delayed complication monitoring of this patient's condition.

A 42-year-old woman is brought to the emergency department complaining of a sudden, excruciating headache that began 3 days ago. She describes it as the worst headache of her life. Physical examination reveals photophobia, mild nuchal rigidity, and no focal neurologic deficits. The physician strongly suspects an acute spontaneous subarachnoid hemorrhage (SAH). Arrange the following diagnostic modalities and imaging studies in the correct sequential order for the comprehensive workup and acute management of this patient. Assume that each initial diagnostic step does not provide a definitive etiology (e.g., negative initial findings) or requires subsequent anatomical delineation.

A 42-year-old woman presents to the emergency department with severe right upper quadrant abdominal pain, fever, and nausea. Acute cholecystitis is highly suspected. Arrange the following imaging modalities in the correct step-wise sequence for evaluating this patient, beginning with the most appropriate initial test, followed by the test used when the initial evaluation is indeterminate, and concluding with the modality reserved for assessing severe complications or alternative diagnoses.

Ten minutes after successful endotracheal intubation for refractory status asthmaticus, a 28-year-old man's mechanical ventilator begins continuously sounding the high peak airway pressure alarm. The patient's blood pressure, previously 122/78 mm Hg, abruptly drops to 62/40 mm Hg, and his heart rate increases from 110/min to 148/min. Physical examination reveals prominent jugular venous distention. The trachea is midline. Chest auscultation demonstrates markedly diminished breath sounds symmetrically across both lung fields with very little chest wall excursion. There is no subcutaneous emphysema. Which of the following is the most appropriate immediate next step in the stabilization of this patient?

Paramedics rush a 24-year-old male to the trauma and resuscitation bay due to unceasing generalized tonic-clonic convulsions. According to his partner, the seizure activity commenced abruptly at their residence 20 minutes prior and has been completely unrelenting. Vital signs cannot be fully obtained due to his violent movements, but pulse oximetry reveals an oxygen saturation of 88% on room air. The patient is deeply unresponsive, actively seizing, and pooling thick secretions in his oropharynx. Multiple attempts by the critical care nurses to place a peripheral intravenous catheter fail because of his continuous, violent thrashing.

Based on fundamental resuscitation principles, arrange the following steps in the optimal chronological sequence to manage this emergency.