All practice questions

A 61-year-old man is evaluated in the hospital for 3 days of fever, dry cough, pleuritic chest pain, and mild hemoptysis. His medical history is significant for an orthotopic heart transplant 3 years ago for nonischemic cardiomyopathy and a history of recurrent unprovoked deep venous thrombosis. His current medications include tacrolimus, mycophenolate mofetil, prednisone, and warfarin.

Vital signs are temperature $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse $102/\text{min}$, blood pressure $118/74\text{ mmHg}$, and respirations $20/\text{min}$. Pulse oximetry shows $94\%$ on room air.

A serum galactomannan assay is markedly elevated. A non-contrast CT of the chest reveals a $3\text{ cm}$ macronodule in the right upper lobe surrounded by a halo of ground-glass attenuation.

The infectious disease service diagnoses invasive pulmonary aspergillosis and recommends initiating intravenous voriconazole.

Which of the following simultaneous pharmacologic interventions are indicated for this patient? (Select all that apply)

A pulmonologist is reviewing surgical lung biopsy reports for four different adult patients, all of whom presented with progressive exertional dyspnea and bilateral interstitial opacities on high-resolution computed tomography. In order to establish the correct clinical diagnosis and formulate an appropriate management plan, the specific histopathological pattern must be correlated with the corresponding disease entity. Match each histopathological biopsy description with its definitive clinical diagnosis.

A 22-year-old college student is brought to the emergency department by his roommates because he is unarousable. He had complained of a severe headache and fever for the past 24 hours. Vital signs show temperature $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), blood pressure 80/40 mm Hg, pulse 135/min, and respirations 28/min. Oxygen saturation is 88% on room air. Physical examination reveals a petechial rash on the lower extremities and nuchal rigidity. The patient only withdraws to pain and does not open his eyes or make any sounds (Glasgow Coma Scale score of 6).

Arrange the following management steps in the most appropriate sequential order for this patient's initial stabilization and diagnostic workup.

A 56-year-old man is evaluated in the clinic for persistent hypertension. He has a 4-year history of elevated blood pressure that remains poorly controlled despite adherence to maximum tolerated doses of amlodipine, lisinopril, and hydrochlorothiazide. His blood pressure today is 162/98 mm Hg. Laboratory studies show a serum potassium level of 3.2 mEq/L and a serum sodium level of 145 mEq/L. The physician suspects primary aldosteronism.

Arrange the following diagnostic interventions in the most appropriate chronological order to establish the diagnosis, localize the pathology, and guide surgical management, assuming each successive test yields abnormal findings that necessitate further workup.

During a routine primary care visit, a 42-year-old man is evaluated for persistently elevated blood pressure. He was diagnosed with hypertension four years ago. Despite documented adherence to a daily regimen containing maximal doses of amlodipine, olmesartan, and chlorthalidone, his home blood pressure readings consistently remain above $150/90 \text{ mm Hg}$. He reports no headaches, palpitations, or episodic sweating. Today, his blood pressure is $162/98 \text{ mm Hg}$, and his pulse is $76/\text{min}$. His body mass index is $26 \text{ kg/m}^2$. Physical examination is unremarkable. Laboratory studies from last week demonstrate a serum potassium level of $2.9 \text{ mEq/L}$ and a sodium level of $144 \text{ mEq/L}$. A plasma aldosterone-to-renin ratio is significantly elevated, and primary aldosteronism is subsequently confirmed via a lack of aldosterone suppression following an intravenous saline infusion test. An unenhanced computed tomography (CT) scan of the abdomen reveals a $1.4\text{-cm}$, lipid-rich, low-density nodule in the right adrenal gland. The left adrenal gland appears morphologically normal. The patient is otherwise healthy, has a good baseline functional status, and expresses a strong preference for definitive surgical management over lifelong medical therapy. Which of the following is the most appropriate next step in management?

A 64-year-old man with a 45-pack-year smoking history presents to his primary care physician complaining of a persistent cough, worsening exertional dyspnea, and an unintentional 5-kg (11-lb) weight loss over the past two months. Physical examination reveals decreased breath sounds and dullness to percussion in the right upper lung field. The physician initiates a diagnostic workup for suspected bronchogenic carcinoma.

Arrange the following imaging studies in the most appropriate evidence-based chronological sequence for the initial detection, regional characterization, and distant metastatic staging of this patient's suspected condition.

Match the following classic multiphasic contrast-enhanced imaging (CT or MRI) findings of the liver with their most likely corresponding hepatic lesion.

A 62-year-old man is brought to the emergency department due to sudden-onset, severe substernal chest pain that radiates to his left jaw. The pain started 45 minutes ago. His blood pressure is 120/80 mmHg, and his heart rate is 90/min. An electrocardiogram shows ST-segment elevations in leads V1 through V4. His medical history includes type 2 diabetes mellitus, hyperlipidemia, and erectile dysfunction. He reports taking sildenafil 12 hours ago for erectile dysfunction. Which of the following medications is absolutely contraindicated in the initial management of this patient's acute presentation?

A 60-year-old man presents to the clinic for a follow-up evaluation. Two weeks ago, he was evaluated in the emergency department for severe left lower quadrant abdominal pain and was diagnosed with acute uncomplicated diverticulitis. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis performed at that time confirmed the diverticulitis and incidentally noted a 3.2-cm, well-circumscribed mass in the right adrenal gland. He has completed a course of oral antibiotics, and his abdominal pain has completely resolved. He has no history of hypertension, palpitations, or weight loss. Blood pressure is 122/78 mm Hg, and pulse is 74/min. Physical examination is unremarkable. Upon review of the initial CT scan report, the adrenal mass has a pre-contrast attenuation of 6 Hounsfield units (HU) and demonstrates an absolute contrast washout of 70% at 15 minutes. Based on the interpretation of these imaging findings, which of the following represents the most accurate diagnosis and the most appropriate next step in management?

A 78-year-old female is evaluated on the inpatient medical ward for acute-onset confusion and agitation. She was admitted two days ago for a mild exacerbation of chronic obstructive pulmonary disease (COPD) and has been receiving nebulized albuterol, systemic corticosteroids, and supplemental oxygen. Last night, she reported insomnia and was administered a dose of over-the-counter oral diphenhydramine. This morning, she is disoriented to place and time, exhibits fluctuating attention, and claims to see insects crawling on her blanket. Her temperature is 37.0°C (98.6°F), blood pressure is 128/78 mm Hg, heart rate is 88/min, and oxygen saturation is 96% on room air. A comprehensive metabolic panel reveals a serum sodium of 134 mEq/L. Urinalysis shows trace bacteriuria but is negative for leukocyte esterase and nitrites. Which of the following should be prioritized at the top of the differential diagnosis for this patient's acute mental status change?

Match each clinical presentation of a patient with a thyroid abnormality to the most appropriate guideline-indicated next step in their diagnostic workup.

A $42$-year-old man comes to the clinic for evaluation of chronic fatigue, mild exertional dyspnea, and recently discovered elevated liver enzymes. He has no history of alcohol use, intravenous drug use, or unprotected sexual intercourse. His body mass index is $23 \text{ kg/m}^2$. Laboratory testing shows an aspartate aminotransferase (AST) of $85 \text{ U/L}$ and an alanine aminotransferase (ALT) of $92 \text{ U/L}$. Serum alkaline phosphatase, total bilirubin, and viral hepatitis serologies are unremarkable. A percutaneous liver biopsy is performed to evaluate the unexplained transaminitis. Microscopic examination of the hepatic parenchyma reveals the presence of intracytoplasmic, round, eosinophilic inclusions predominantly within periportal hepatocytes. These inclusions stain strongly positive with periodic acid-Schiff (PAS) and resist digestion by diastase. Which of the following is the most likely diagnosis based on these histopathologic findings?

A 52-year-old woman is evaluated in the hospital for sudden-onset, severe shortness of breath. She was admitted earlier today for management of osteomyelitis and recently underwent placement of a right internal jugular central venous catheter. Her blood pressure is 78/40 mmHg, pulse is 134/min, and oxygen saturation is 82% on room air. On physical examination, she is in severe respiratory distress and is diaphoretic. The trachea is deviated to the left. The neck veins are visibly distended. Breath sounds are completely absent over the right hemithorax, and the right chest is hyperresonant to percussion. Which of the following is the most appropriate next step in management of this patient?

A 32-year-old man with a known history of epilepsy is brought to the emergency department by ambulance. His roommate reports that the patient has been experiencing continuous generalized tonic-clonic movements for the past 20 minutes without regaining consciousness. Upon arrival, the patient is actively seizing. The airway is secured, and peripheral intravenous access is immediately established. Arrange the following pharmacologic interventions in the correct sequential order of escalation for the management of status epilepticus, from first-line therapy to refractory management.

A 52-year-old man undergoes an unenhanced computed tomography (CT) scan of the abdomen and pelvis to evaluate suspected nephrolithiasis after recently passing a calcium oxalate stone. The scan reveals an incidental 4.6-cm, well-circumscribed left adrenal mass with an unenhanced attenuation of 28 Hounsfield units. The right adrenal gland is normal. The patient is completely asymptomatic. He has no history of hypertension, palpitations, headaches, or weight changes. He takes no medications. Vital signs are temperature 37.1°C (98.8°F), blood pressure 118/76 mm Hg, heart rate 72/min, and respiratory rate 14/min. Physical examination reveals no abdominal bruits, purple striae, central adiposity, or abnormal fat distribution. Serum potassium is 4.3 mEq/L and serum creatinine is 0.9 mg/dL. Which of the following is the most appropriate next step in the diagnostic workup?

Emergency medical services arrive at the trauma bay with a 35-year-old construction worker who fell approximately 20 feet from scaffolding. On presentation, the patient is obtunded with gurgling respirations and profound maxillofacial bleeding. The cardiac monitor displays a sinus tachycardia of 138/min. Noninvasive blood pressure is 75/40 mm Hg, and respiratory rate is 28/min.

According to standard trauma resuscitation protocols, arrange the following initial stabilization steps in the most appropriate chronological sequence.

A 48-year-old female is evaluated in the emergency department for a sudden, severe headache that reached maximum intensity within seconds, accompanied by photophobia and nausea. She has a history of autosomal dominant polycystic kidney disease (ADPKD). Her blood pressure is 172/98 mmHg. Neurological examination shows no focal deficits, but nuchal rigidity is present. She is admitted for comprehensive management of a suspected ruptured intracranial aneurysm.

Arrange the following imaging modalities in the correct chronological sequence reflecting standard guidelines for the initial diagnosis, vascular mapping, definitive periprocedural evaluation, and subsequent neurocritical care monitoring of this patient.

During a routine health maintenance examination, a physician detects an asymmetric neck swelling in a previously healthy 48-year-old female. The patient reports a 3-kg (6.6-lb) unintentional weight loss over the past two months and describes intermittent episodes of a 'racing heart.' Vital signs show a heart rate of 98/min and a blood pressure of 128/82 mmHg. Physical examination reveals a firm, mobile, 2.5-cm mass in the right anterior neck that moves with swallowing. No cervical lymphadenopathy is appreciated. Laboratory evaluation demonstrates a thyroid-stimulating hormone (TSH) level of 0.08 µU/mL (normal: 0.4–4.0 µU/mL) and a free thyroxine (T4) level of 2.1 ng/dL (normal: 0.8–1.8 ng/dL). A comprehensive neck ultrasound identifies a 2.6-cm solid, mildly hypoechoic nodule in the right thyroid lobe with increased central vascularity. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's condition?

A 71-year-old man presents to the emergency department with the sudden onset of severe, diffuse abdominal pain that began two hours ago. He has a 10-year history of severe osteoarthritis and takes high-dose naproxen daily. His temperature is 37.8°C (100.0°F), blood pressure is 100/60 mm Hg, pulse is 115/min, and respirations are 24/min. On physical examination, the patient appears acutely ill and is lying completely still on the stretcher. The abdomen is rigid with diffuse involuntary guarding and pronounced rebound tenderness. An upright chest radiograph is obtained and demonstrates a prominent, crescent-shaped radiolucency located immediately beneath the right hemidiaphragm, clearly separating it from the liver shadow. Based on the interpretation of this radiograph, which of the following is the most appropriate next step in management?

A 54-year-old man presents to the clinic with a 3-week history of progressive bilateral lower extremity edema and frothy urine. He has no past medical history and takes no medications. Blood pressure is 142/88 mmHg. Physical examination reveals 3+ pitting edema up to the mid-calves. Laboratory studies show a serum albumin of 2.2 g/dL, serum creatinine of 0.9 mg/dL, and a 24-hour urine protein excretion of 6.4 g. Hepatitis B, hepatitis C, and HIV serologies are negative. A percutaneous renal biopsy is performed. Light microscopy reveals diffuse thickening of the glomerular basement membranes and capillary walls throughout all glomeruli, notably without a significant increase in mesangial or endothelial cellularity. Based on the most likely diagnosis, which of the following additional biopsy findings would correctly support this patient's diagnosis? (Select all that apply)