All practice questions

A 67-year-old man presents to the urology clinic to discuss the results of a recent 12-core transrectal ultrasound-guided prostate biopsy. The biopsy was performed after two consecutive elevated prostate-specific antigen (PSA) measurements (most recently 6.8 ng/mL) and a normal digital rectal examination. The pathology report confirms invasive prostatic adenocarcinoma in two cores from the right peripheral zone. The multidisciplinary tumor board is reviewing the histopathologic architecture to determine the International Society of Urological Pathology (ISUP) Grade Group, which is critical for deciding whether the patient is a candidate for active surveillance or requires definitive therapy. Which of the following microscopic architectural patterns specifically define a Gleason pattern 4 tumor? (Select all that apply)

A 42-year-old woman presents to the emergency department with sudden-onset, severe right upper quadrant abdominal pain that radiates to her right shoulder. The pain began one hour ago after she consumed a large, fatty meal. She reports experiencing similar, though less severe, episodes over the past few months that usually resolved spontaneously within a few hours. Her temperature is 37.1°C (98.8°F), pulse is 88/min, respirations are 16/min, and blood pressure is 128/82 mm Hg. Physical examination reveals tenderness to palpation in the right upper quadrant, but no rebound tenderness, guarding, or jaundice. Which of the following is the most appropriate next step in the diagnostic workup?

A 25-year-old woman is brought to the emergency department by a friend due to the sudden onset of difficulty breathing, throat tightness, and a diffuse itchy rash. Her symptoms began 15 minutes ago, shortly after she ate a peanut butter cookie at a local bakery. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 82/50 mm Hg, pulse of 128/min, and respirations of 28/min. Oxygen saturation is 92% on room air. Physical examination reveals diffuse urticaria, facial edema, and bilateral expiratory wheezing. Which of the following is the most appropriate immediate next step in management?

An inpatient on the internal medicine ward, a 69-year-old male being treated for community-acquired pneumonia, acutely develops intense lower back pain radiating down both legs. The nursing staff notes that he has been unable to void urine for the past 10 hours and he complains of numbness in his groin. His medical history includes ischemic cardiomyopathy with a legacy implantable cardioverter-defibrillator (ICD) placed 12 years ago that is documented as non-MRI-conditional. Vital signs are within normal limits. Neurologic evaluation demonstrates diminished strength in bilateral ankle plantar flexion, absent Achilles reflexes, and loss of pinprick sensation in the perianal region. Digital rectal examination reveals markedly decreased sphincter tone. Postvoid residual volume by bladder scan is 750 mL. The clinical team strongly suspects an acute compression of the lumbosacral nerve roots. Which of the following is the most appropriate next step in imaging to confirm the diagnosis?

Match each patient presentation with the most appropriate next step in their diagnostic evaluation based on established sequential testing algorithms.

A 22-year-old male college student presents to the student health clinic with a 2-day history of a severe sore throat, fever of 38.8°C (101.8°F), and profound fatigue. Physical examination reveals bilateral tonsillar exudates, tender posterior cervical lymphadenopathy, and a palpable spleen tip. Arrange the following conditions in order from the most likely to the least likely diagnosis based on this patient's clinical presentation.

Match the following pathognomonic central nervous system magnetic resonance imaging (MRI) findings with their most likely corresponding underlying neurodegenerative or metabolic condition.

A 43-year-old female presents to the emergency department complaining of severe right upper quadrant abdominal pain that began three hours ago, shortly after eating a large, high-fat meal. She reports associated nausea and one episode of vomiting. Her temperature is 38.1°C (100.6°F), blood pressure is 128/82 mmHg, and heart rate is 92/min. Physical examination reveals marked tenderness to palpation in the right upper quadrant, and the patient abruptly halts her inspiration when deep palpation is applied in this area. Laboratory studies show a mildly elevated white blood cell count. Which of the following is the most appropriate initial imaging study to establish the diagnosis?

A hepatobiliary tumor board is reviewing the pathologic and immunohistochemical findings of five distinct hepatic lesions to finalize their diagnoses. Which definitive pathologic diagnosis best matches each histopathologic description and biomarker profile?

A 58-year-old man with a 15-year history of type 2 diabetes mellitus and peripheral neuropathy presents to the clinic for evaluation of a chronic right foot ulcer. He first noticed the ulcer 6 weeks ago, and it has not improved despite offloading and regular dressing changes. He is afebrile, and his vital signs are within normal limits. Physical examination reveals a 2.5-cm, deep, neuropathic ulcer on the plantar aspect of the right first metatarsal head. The base of the ulcer contains pale granulation tissue and mild purulent discharge. The surrounding skin is indurated and erythematous. A sterile blunt probe introduced into the ulcer does not palpate a hard, gritty surface (negative probe-to-bone test). The physician suspects early diabetic foot osteomyelitis.

Arrange the following diagnostic and therapeutic steps in the most appropriate chronological order to accurately evaluate and definitively manage this patient's condition.

A 38-year-old woman is evaluated in the ambulatory setting for recent, unexplained weight gain and new-onset hypertension. Over the past eight months, she has gained $14$ kg despite no changes to her diet or physical activity level. She also reports increasing difficulty climbing stairs and easy bruising on her extremities. Blood pressure is $158/96$ mmHg. Physical examination reveals facial plethora, prominent dorsocervical and supraclavicular fat pads, and broad violaceous striae across the lower abdomen. Initial screening for hypercortisolism is performed using a $1$-mg overnight dexamethasone suppression test. Her serum cortisol level at 8:00 AM the following morning is $14 \mu\text{g/dL}$ (normal: $<1.8 \mu\text{g/dL}$). Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

Following a high-speed collision with a commercial delivery van, a 31-year-old male pedestrian is airlifted to the regional trauma center. His electronic health record indicates no significant past medical history. During transport, the flight medical crew placed a rigid cervical collar and secured two large-bore peripheral intravenous catheters. Upon arrival, the patient is minimally responsive, groaning, and localizing to painful stimuli. Vital signs show a temperature of 35.8°C (96.4°F), blood pressure of 74/42 mm Hg, heart rate of 142/min, and respiratory rate of 28/min. His extremities are cool with weak, thready pulses. The primary survey reveals an unobstructed airway with bilateral and equal breath sounds. Evaluation of the abdomen demonstrates marked suprapubic ecchymosis and guarding. Gentle manual compression of the iliac crests reveals mechanical instability of the pelvic ring. A focused assessment with sonography for trauma (FAST) demonstrates an absence of free fluid in the pericardial, right upper quadrant, left upper quadrant, and pelvic views. A portable chest radiograph displays no acute cardiopulmonary abnormalities. Which of the following is the most appropriate next step in the immediate stabilization of this patient?

An internal medicine physician evaluates a 71-year-old man who is referred due to progressively worsening fatigue and dyspnea on exertion over the past 4 months. Complete blood count reveals a hemoglobin of $8.2 \text{ g/dL}$, mean corpuscular volume of $106 \text{ fL}$, leukocyte count of $3,100/\text{mm}^3$, and platelet count of $92,000/\text{mm}^3$. Vitamin B12 and folate levels are within normal limits. A bone marrow aspiration and trephine biopsy are performed. The synoptic histopathology report describes a hypercellular marrow for age ($85\%$ cellularity) with marked erythroid predominance. Silver staining is negative for reticulin fibrosis. Iron staining reveals that $25\%$ of the nucleated red blood cell precursors have iron granules encircling the nucleus. Dysplastic features are prominent in the megakaryocytic lineage, including several small, mononuclear megakaryocytes. The blast count is estimated at $3\%$. Based on the integrated clinical and biopsy findings, which of the following is the most definitive diagnosis?

A 65-year-old man is evaluated in the intensive care unit for recurrent large-volume hematochezia. He originally presented to the emergency department 24 hours ago with bright red blood per rectum and hypotension. His medical history includes hypertension, hyperlipidemia, and coronary artery disease. Following initial resuscitation with intravenous crystalloids and two units of packed red blood cells, his vital signs normalized. A nasogastric lavage returned clear fluid with no blood or coffee-ground material. An urgent upper gastrointestinal endoscopy demonstrated a normal esophagus, stomach, and duodenum. Following rapid bowel preparation, a colonoscopy was performed which revealed scattered diverticula and fresh blood throughout the colon, but no active bleeding site could be identified.

While in the intensive care unit, the patient passes another large, bloody stool. His blood pressure drops to 95/65 mmHg and his heart rate increases to 118/min.

Which of the following is the most appropriate next step in the diagnostic workup?

A 45-year-old man is evaluated in the outpatient clinic for a three-day history of progressive left leg swelling and pain. He recently returned from a 12-hour international flight. His past medical history is unremarkable, and he takes no medications. Vital signs are stable. Physical examination reveals pitting edema, erythema, and marked tenderness along the deep venous system of the left calf. The left calf circumference is 5 cm larger than the right calf. Based on clinical criteria, the patient has a high pretest probability for a deep vein thrombosis. Which of the following is the most appropriate initial step in the diagnostic workup?

A 29-year-old woman, G2P1, at 26 weeks gestation is brought to the emergency department due to a 2-hour history of sudden-onset shortness of breath and right-sided pleuritic chest pain. She has no significant past medical history and takes only prenatal vitamins. Her vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 118/76 mmHg, heart rate of 112/min, respiratory rate of 24/min, and oxygen saturation of 94% on ambient air. Physical examination reveals clear lungs to auscultation bilaterally. The right calf is visibly swollen, erythematous, and tender to palpation compared to the left. Which of the following diagnostic studies should be ordered as the most appropriate initial steps in this patient's evaluation? (Select exactly 2)

A 65-year-old man with a 30-pack-year smoking history is evaluated in the clinic. A preoperative chest radiograph performed for an upcoming elective hernia repair reveals an incidental 12-mm, non-calcified solitary pulmonary nodule in the right upper lobe. Arrange the following diagnostic steps in the most appropriate sequential order for the evaluation of this imaging finding, from the initial step to definitive diagnosis.

A 58-year-old man undergoes an upper gastrointestinal endoscopy for evaluation of progressive early satiety, postprandial nausea, and a 9-kg (20-lb) weight loss over the past 4 months. During the procedure, the endoscopist notes a diffusely thickened, rigid gastric body and antrum with poor distensibility upon air insufflation. No discrete exophytic mass or large ulcer is visualized. Multiple deep mucosal biopsies are obtained. Which of the following histopathologic and immunohistochemical findings are characteristic of this patient's most likely diagnosis? (Select all that apply)

A 38-year-old man is evaluated in the emergency department for a 2-day history of severe, diffuse abdominal pain. Over the last six months, he has had recurrent episodes of profound fatigue, intermittent difficulty swallowing, and noting that his urine is occasionally unusually dark, particularly with his first morning void. He also mentions a recent onset of erectile dysfunction, which he attributed to stress. He takes no medications and does not use tobacco, alcohol, or illicit drugs. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure 138/86 mm Hg, heart rate 108/min, and respiratory rate 18/min. Physical examination reveals marked pallor and scleral icterus. The abdomen is diffusely tender without rebound or guarding. Bowel sounds are hypoactive.

Laboratory findings are as follows:

Direct antiglobulin (Coombs) test is negative.
Urinalysis reveals 4+ blood with 0-2 red blood cells/hpf.

A contrast-enhanced CT scan of the abdomen reveals superior mesenteric vein thrombosis without bowel infarction.

Which of the following is the most likely underlying condition causing this patient's presentation?

A 65-year-old man with a 40-pack-year smoking history visits the clinic for a routine evaluation. A screening chest radiograph reveals a new 15-mm noncalcified solitary pulmonary nodule in the right upper lobe. No previous chest radiographs are available for comparison. Arrange the following diagnostic modalities in the most appropriate standard chronological sequence for the evaluation of this patient's pulmonary nodule.