All practice questions

A 45-year-old man presents to an urgent care center with a 1-day history of right lower quadrant abdominal pain, nausea, and low-grade fever. He mentions that he returned two days ago from a business trip to a region with endemic typhoid fever. The attending physician, who earlier that morning read a public health advisory regarding travel-associated gastrointestinal infections, immediately suspects a tropical enteric infection. The physician orders stool studies and empirical antimicrobial therapy. Shortly after, during the physical examination, the physician notes exquisite rebound tenderness at McBurney's point, and a laboratory report shows a white blood cell count of $16,500 \text{ /mm}^3$. The physician dismisses these findings, attributing the leukocytosis and tenderness to severe infectious gastroenteritis, and proceeds to discharge the patient with oral antibiotics. Twelve hours later, the patient is admitted to a local hospital with a ruptured appendix.

Which of the following cognitive errors were demonstrated by the physician in this scenario? (Select all that apply)

A 45-year-old man presents to the clinic complaining of increasing ring and shoe size over the past three years. He also reports excessive sweating, worsening snoring, and joint pain. Physical examination reveals coarse facial features, a prominent jaw, and enlarged, doughy hands. The physician strongly suspects a condition caused by a hyperfunctioning anterior pituitary adenoma. What is the correct sequence of the following diagnostic steps to evaluate this patient's condition? Arrange the items from the initial screening test to the final localization study.

A 76-year-old woman is brought to the emergency department by her family due to the sudden onset of severe abdominal pain that began 4 hours ago. The patient has a history of paroxysmal atrial fibrillation, for which she was prescribed apixaban but admits to missing multiple doses over the past week. She also has stage 3b chronic kidney disease and hypertension.

On arrival, her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $92/58 \text{ mmHg}$, pulse is $128/\text{min}$ and irregularly irregular, and respiratory rate is $22/\text{min}$. Physical examination reveals a soft, non-distended abdomen with only mild, diffuse tenderness to deep palpation. There is no guarding, rigidity, or rebound tenderness. Bowel sounds are absent.

Laboratory studies show:
Leukocyte count: $18,500/\text{mm}^3$
Hemoglobin: $12.2 \text{ g/dL}$
Serum creatinine: $2.1 \text{ mg/dL}$ (baseline $1.8 \text{ mg/dL}$)
Serum lactate: $6.8 \text{ mmol/L}$ (Normal: $0.5 - 1.0 \text{ mmol/L}$)

Due to concerns regarding her acute-on-chronic kidney injury, a non-contrast computed tomography (CT) scan of the abdomen and pelvis is performed. The radiologist reports diffuse bowel wall thickening involving the jejunum and proximal ileum. Additionally, there are linear gas collections within the wall of the affected small bowel segments, and branching, tubular areas of gas extending to the periphery of the right hepatic lobe.

Based on the imaging findings, which of the following is the most appropriate next step in management?

Paramedics transport a 19-year-old man to the trauma bay following a headfirst diving accident in a shallow lake. On arrival, he is apneic and completely unresponsive to noxious stimuli. Emergency medical personnel are actively providing assisted ventilation via a bag-valve-mask device. His temperature is $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), blood pressure is $72/40\text{ mmHg}$, heart rate is $44\text{/min}$, and oxygen saturation is $94\%$ on $100\%$ oxygen. Physical examination reveals flaccid paralysis and absent deep tendon reflexes in all four extremities. A $6\text{-cm}$ scalp laceration over the vertex is actively oozing blood.

Arrange the following initial management steps in the most appropriate chronological order.

A 64-year-old man with a history of hypertension and hyperlipidemia is brought to the emergency department by ambulance due to severe, crushing substernal chest pain that began 45 minutes ago while shoveling snow. The patient is pale, profusely diaphoretic, and appears in acute distress. Vital signs are temperature 36.6°C (97.9°F), heart rate 42/min, blood pressure 72/40 mm Hg, respiratory rate 22/min, and oxygen saturation 96% on room air. Physical examination reveals marked jugular venous distention. Auscultation of the chest demonstrates clear lung fields bilaterally with no murmurs or gallops. An immediate 12-lead electrocardiogram shows 3-mm ST-segment elevations in leads II, III, and aVF, with reciprocal ST-segment depressions in leads I and aVL. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old man is admitted to the hospital with a 14-day history of unremitting fevers up to 39.8°C (103.6°F), drenching night sweats, and progressive lethargy. Ten days ago, he returned from a camping trip in the northeastern United States. He was initially evaluated at an urgent care clinic 5 days ago, diagnosed with a suspected tick-borne illness, and prescribed oral doxycycline. His symptoms have worsened despite perfect medication adherence. He has no significant past medical history.

On physical examination, the patient appears ill and pale. Temperature is 39.6°C (103.3°F), blood pressure is 105/65 mm Hg, pulse is 115/min, and respirations are 20/min. Cardiopulmonary examination is unremarkable. Abdominal examination reveals a firm, palpable spleen edge 6 cm below the left costal margin; there is no hepatomegaly. No skin rashes or eschars are noted.

Laboratory testing reveals:

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

A root cause analysis (RCA) is conducted after a 4-year-old child in the pediatric intensive care unit mistakenly receives a 10-fold overdose of continuous intravenous morphine, resulting in respiratory arrest requiring intubation. The committee identifies several vulnerabilities and proposes multiple corrective actions based on the hierarchy of safety controls. Match each proposed corrective action to its correct classification within the hierarchy of safety interventions based on its anticipated effectiveness.

Match the following classic High-Resolution Computed Tomography (HRCT) of the chest findings with their most likely corresponding interstitial lung disease diagnosis.

Formulating an accurate differential diagnosis for acute monoarticular or oligoarticular joint pain requires distinguishing among competing etiologies based on specific clinical findings. Match each patient's clinical presentation with the most likely diagnosis on the differential.

A 72-year-old man comes to the primary care clinic for evaluation of a 3-week history of painless yellowing of his eyes and skin, dark urine, pale stools, and an unintentional 6.8-kg (15-lb) weight loss. Vital signs are stable. Physical examination reveals marked scleral icterus and a palpable, non-tender mass in the right upper abdominal quadrant. Laboratory testing shows a total bilirubin of 14.2 mg/dL, direct bilirubin of 11.5 mg/dL, and a significantly elevated alkaline phosphatase level. Arrange the following diagnostic imaging and interventional modalities in the most appropriate chronological sequence for the evaluation and staging of this patient's suspected condition.

A $55$-year-old woman is evaluated in the surgical oncology clinic to discuss the final pathology report from her recent total thyroidectomy. The surgery was performed after a fine-needle aspiration of a $2.5$ cm solid, hypoechoic right thyroid nodule with microcalcifications returned as suspicious for malignancy. The preliminary intraoperative frozen section revealed complex branching structures with central fibrovascular cores. Based on this patient's presentation and architectural tissue findings, which of the following cytopathologic and histopathologic features are expected in the final synoptic report to establish the definitive diagnosis? (Select all that apply)

A 55-year-old man is evaluated in the emergency department for left leg pain and swelling that began 24 hours ago. He has a history of colon cancer and is currently undergoing active chemotherapy. His temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, heart rate is 88/min, and respiratory rate is 14/min. Physical examination reveals a visibly swollen, tense, and erythematous left lower extremity. The left calf circumference is 5 cm larger than the right calf. There is no chest pain or shortness of breath. Which of the following is the most appropriate next step in the diagnostic workup for this patient?

A 61-year-old man arrives at the emergency department reporting severe, crushing substernal chest pain that radiates to his jaw, accompanied by profound diaphoresis and nausea. The symptoms began abruptly 45 minutes prior. His past medical history is notable for hypertension, type 2 diabetes mellitus, and hyperlipidemia. Vital signs are temperature 36.8°C (98.2°F), heart rate 112/min, blood pressure 74/48 mm Hg, respiratory rate 22/min, and oxygen saturation 96% on room air. Physical examination reveals elevated jugular venous pressure with prominent a-waves. Pulmonary auscultation reveals clear breath sounds bilaterally without crackles or wheezes. A 12-lead electrocardiogram demonstrates 3-mm ST-segment elevations in leads II, III, and aVF, with reciprocal ST-segment depressions in leads I and aVL. Which of the following is the most urgent initial step in the management of this patient?

Emergency medical services bring a 59-year-old man to the acute care bay for evaluation of rapidly progressive lower extremity weakness. For the past week, the patient has experienced dull, constant, mid-thoracic back pain and subjective fevers, which he initially attributed to a mechanical strain. Over the last 12 hours, he developed difficulty walking and urinary retention. His medical history is significant for end-stage renal disease on hemodialysis, type 2 diabetes mellitus, and sick sinus syndrome. He had a non-MRI-conditional dual-chamber permanent pacemaker placed 14 years ago. His temperature is 38.8°C (101.8°F), blood pressure is 112/74 mm Hg, and pulse is 95/min. Physical examination reveals exquisite tenderness to percussion over the T8 to T10 spinous processes. Neurologic examination shows 2/5 strength in bilateral hip flexors and knee extensors, hyperreflexia at the patellae, and a positive Babinski sign bilaterally. Sensation to pinprick is markedly decreased below the umbilicus. Anal sphincter tone is diminished. Laboratory studies show a leukocyte count of 18,500/mm³ and an erythrocyte sedimentation rate of 92 mm/h. Which of the following is the most appropriate next step in imaging for this patient?

A 47-year-old female pedestrian is struck by a commercial delivery truck and brought directly to the trauma resuscitation bay. On arrival, she is lethargic, diaphoretic, and pale. Vital signs include a heart rate of 145/min, blood pressure of 65/35 mmHg, and respiratory rate of 28/min. Pulse oximetry is currently unreadable due to poor peripheral perfusion. The primary survey reveals clear, equal breath sounds bilaterally and no obvious source of external hemorrhage. The pelvis is highly unstable to gentle anteroposterior compression, and the right thigh is significantly swollen and deformed. Two large-bore peripheral intravenous lines are immediately established. Which of the following are the most appropriate immediate next steps in the stabilization of this patient? (Select all that apply)

Emergency Medical Services arrives at the trauma bay with a 28-year-old construction worker who fell approximately 30 feet from scaffolding. Upon transfer to the resuscitation stretcher, the patient demonstrates decerebrate posturing, absent vocalizations, and no eye opening to sternal rub.

Initial assessment reveals the following vital parameters:
- Temperature: 36.2°C (97.2°F)
- Heart rate: 138/min
- Blood pressure: 78/42 mm Hg
- Respiratory rate: 8/min (shallow and irregular)
- Oxygen saturation: 88% on ambient air

A rapid physical survey identifies a large, actively bleeding avulsion of the right parietal scalp. Neurologic evaluation shows anisocoria, with the right pupil fixed and dilated at 7 mm while the left is 3 mm and reactive. The left thigh exhibits massive swelling and a noticeable angular deformity.

Arrange the following management steps in the most appropriate chronological sequence of execution to stabilize this critically ill patient.

Evaluate the following patients presenting with upper gastrointestinal symptoms. Match each clinical presentation to the most appropriate next step in their diagnostic workup.

A 65-year-old woman with a history of prior abdominal surgeries is admitted for suspected mechanical small bowel obstruction. If the condition remains unresolved and progresses to bowel ischemia and eventual perforation, arrange the following imaging findings in their typical chronological order of appearance on abdominal imaging.

Match each clinical presentation of gastrointestinal bleeding with the most appropriate next step in the diagnostic workup.

A 36-year-old woman presents to the clinic with progressive weight gain, fatigue, and easy bruising over the past 8 months. She also reports irregular menstrual periods and new-onset facial hair growth. Blood pressure is 158/98 mmHg, pulse is 82/min, and BMI is 34 kg/m². Physical examination reveals facial plethora, prominent dorsocervical and supraclavicular fat pads, wide purple abdominal striae, and significant weakness when rising from a seated position. A baseline metabolic panel demonstrates a fasting blood glucose of 145 mg/dL and a serum potassium of 3.3 mEq/L. The physician suspects a specific endocrine disorder. Assuming positive or equivocal findings at each step that require further investigation, arrange the following diagnostic tests in the most appropriate chronological order to establish the diagnosis and definitive etiology, from initial screening to final preoperative localization.