All practice questions

A 38-year-old man is evaluated in the preoperative clinic prior to a scheduled open reduction and internal fixation of a severely displaced tibial plateau fracture. The procedure is planned for 3 days from today. His medical history is notable for severe opioid use disorder, which has been in sustained remission for 4 years. He is maintained on a stable daily dose of sublingual buprenorphine-naloxone (16 mg / 4 mg). He has no other chronic medical conditions and takes no other medications. Vital signs are within normal limits. The patient expresses significant anxiety regarding postoperative pain control and fears that his current medication will interfere with his pain management. Which of the following is the most appropriate pharmacologic strategy regarding his opioid use disorder therapy in the perioperative period?

A 54-year-old man is rushed to the emergency department after his wife found him collapsed on the bathroom floor surrounded by a large amount of bright red vomit. He has a known history of alcohol-associated cirrhosis. Upon arrival, he is lethargic, obtunded, and only withdrawing from painful stimuli. Vital signs are temperature 36.5°C (97.7°F), blood pressure 75/40 mmHg, pulse 138/min, and respirations 28/min. Pulse oximetry shows 88% on room air. Physical examination reveals cool, diaphoretic skin, profound scleral icterus, and a distended abdomen with a palpable fluid wave. The physician notes audible gurgling in his upper airway, and there is active, ongoing hematemesis from the patient's mouth.

Arrange the following management steps in the most appropriate chronological order for this patient's initial stabilization and triage.

A 66-year-old woman is evaluated in the clinic following an incidental finding on an abdominal ultrasound, which was performed during a workup for asymptomatic microscopic hematuria. She currently has no abdominal pain, nausea, vomiting, steatorrhea, or weight loss. She has no history of acute or chronic pancreatitis, and she does not consume alcohol. Physical examination reveals a soft, non-tender abdomen with no palpable masses. Liver function tests, serum lipase, and basic metabolic panel are within normal limits.

To further characterize the ultrasound finding, a multiphasic contrast-enhanced MRI of the abdomen with magnetic resonance cholangiopancreatography (MRCP) is performed. The imaging reveals a 3.6-cm, well-demarcated, multilocular cystic lesion located in the head of the pancreas. The mass is composed of numerous clustered microcysts, the majority of which are less than 5 mm in diameter, creating a "honeycomb" appearance. A prominent central, stellate scar is noted, which demonstrates delayed enhancement following gadolinium administration. The main pancreatic duct measures 2.2 mm in diameter, and there is no visible communication between the cystic lesion and the pancreatic ductal system. No mural nodules, peripheral eggshell calcifications, or biliary ductal dilation are present.

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

Match each of the following peripartum or postpartum patient presentations with the most accurate diagnosis. Select the condition that best explains the unique combination of clinical timing and laboratory findings.

Match each focal hepatic lesion to its characteristic histopathologic and immunohistochemical findings typically seen on a needle core biopsy or surgical resection.

A 68-year-old man is brought to the emergency department by ambulance 30 minutes after his wife noticed him slurring his words and unable to move his right arm and leg. He has a medical history of hypertension and type 2 diabetes mellitus. His blood pressure is 180/100 mm Hg, pulse is 92/min, and respirations are 16/min. Neurologic examination reveals right-sided facial droop, right-sided hemiparesis, and expressive aphasia. Which of the following are the most appropriate immediate next steps in the diagnostic workup? (Select two)

A 48-year-old man comes to the emergency department with a 12-hour history of severe, constant epigastric pain that radiates to his back. The pain is accompanied by intractable nausea and non-bilious vomiting. He has a 10-year history of heavy alcohol use but states his last drink was 2 days ago. His medical history is otherwise unremarkable. Temperature is 37.8°C (100.0°F), blood pressure is 142/88 mmHg, pulse is 115/min, and respirations are 20/min. Physical examination reveals a distressed patient leaning forward on the stretcher. Abdominal examination shows marked epigastric tenderness to deep palpation with guarding, but no rebound tenderness or rigidity. Bowel sounds are hypoactive. Which of the following are the most appropriate initial steps in the diagnostic workup for this patient? (Select the 2 correct answers)

Emergency medical services bring a 64-year-old man to the emergency department after he collapsed at his workplace. Prior to losing consciousness, he complained of an agonizing, tearing pain radiating to his interscapular region. Upon arrival, he is lethargic and pale. Vital signs are temperature 36.8°C (98.2°F), blood pressure 75/40 mmHg in the right arm and 60/35 mmHg in the left arm, heart rate 132/min, and respiratory rate 26/min. Oxygen saturation is 96% on room air. Physical examination reveals prominently distended neck veins. The lungs are clear to auscultation bilaterally. Cardiac auscultation reveals distant heart sounds and a high-pitched, decrescendo diastolic murmur heard most loudly at the right upper sternal border. Radial pulses are markedly weaker on the left compared to the right. A point-of-care ultrasound of the heart demonstrates a large pericardial effusion with right ventricular collapse during diastole. Which of the following is the most appropriate immediate next step in the management of this patient?

A 41-year-old previously healthy man comes to the physician because of progressive exertional dyspnea over the last 14 months. He is a lifetime non-smoker and reports rare alcohol consumption. Physical examination is notable for decreased breath sounds at the lung bases and mild hepatomegaly. Initial laboratory testing reveals elevated serum aspartate aminotransferase and alanine aminotransferase levels. To further investigate the hepatic findings, a percutaneous liver biopsy is obtained. Histopathologic examination of the specimen demonstrates intracytoplasmic, round, eosinophilic globules predominantly within periportal hepatocytes. Special staining reveals that these globular inclusions are strongly periodic acid-Schiff (PAS) positive and resist degradation when treated with diastase enzymes. Based on these biopsy findings, which of the following is the most likely diagnosis?

An otherwise healthy 21-year-old female college student presents to the emergency department complaining of severe, right-sided pelvic pain with a sudden onset 5 hours prior while she was exercising. The pain is sharp, non-radiating, and accompanied by nausea and two episodes of emesis. Her last menstrual period was 3 weeks ago, and her cycles are regular. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $118/76\text{ mmHg}$, pulse $98/\text{min}$, and respiratory rate $16/\text{min}$. Physical examination reveals exquisite tenderness to palpation in the right lower quadrant with voluntary guarding, but no rebound tenderness is elicited. Pelvic examination demonstrates right adnexal fullness and tenderness without cervical motion tenderness. A urine pregnancy test is negative. Complete blood count shows a leukocyte count of $8,500/\mu\text{L}$. Transvaginal ultrasonography demonstrates a $6.5 \times 5.0 \times 4.5\text{ cm}$ right ovary with a heterogeneous, echogenic central stroma and multiple small, peripherally displaced follicles. Color Doppler evaluation reveals the presence of arterial spectral waveforms within the right ovarian parenchyma, but venous flow is completely absent. The left ovary measures $2.5 \times 2.0 \times 1.5\text{ cm}$ and demonstrates both continuous venous and low-resistance arterial flow. The appendix measures $5\text{ mm}$ in maximal diameter and is compressible. A small amount of simple free fluid is noted in the rectouterine pouch. Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in management?

A 28-year-old man comes to the clinic for evaluation of a painless ulcer on his penis that appeared one week ago. He has no other symptoms and feels well. He is sexually active with multiple partners. His medical history is significant for an episode of severe anaphylaxis, including throat swelling and hypotension, after receiving amoxicillin at age 12. He takes no daily medications. Vital signs are within normal limits. Physical examination reveals a 1.5-cm, indurated, painless ulcer with a clean base on the glans penis. There is bilateral, non-tender inguinal lymphadenopathy. Dark-field microscopy of a sample from the ulcer exudate shows motile spirochetes. Which of the following is the most appropriate pharmacologic intervention for this patient?

A 19-year-old male college student is transported to the emergency department after suddenly developing severe difficulty breathing and facial swelling while at a local seafood restaurant. He states that his throat feels tight. He has no known past medical history and takes no daily medications. On presentation, the patient is visibly anxious and using accessory muscles of respiration. Temperature is $37.0^\circ$ C ($98.6^\circ$ F), blood pressure is $86/50$ mmHg, pulse is $128$/min, respirations are $28$/min, and oxygen saturation is $94\%$ on room air. Physical examination reveals audible stridor, diffuse bilateral wheezing, and raised, erythematous plaques on his anterior chest. Which of the following is the most appropriate initial step in the management of this patient?

A 62-year-old man with a 40-pack-year smoking history undergoes a routine chest radiograph prior to an elective inguinal hernia repair. The radiograph reveals a newly identified, 15-mm non-calcified nodule in the right upper lobe. He has no significant past medical history, and his physical examination is unremarkable. Assuming each diagnostic step continues to demonstrate a high risk of malignancy without definitively benign features, arrange the following interventions in the most appropriate chronological sequence for the radiographic and diagnostic evaluation of this patient.

A 70-year-old man is transferred to the medical intensive care unit (MICU) from a long-term acute care hospital for management of acute respiratory failure. On admission, a routine axilla and groin screening swab returns positive for *Candida auris*. The patient is appropriately placed on Contact Precautions. Two weeks later, an outbreak investigation is initiated when three other patients in the same MICU develop *C. auris* candidemia. An infection control audit reveals the following:

- 100% staff compliance with hand hygiene before and after patient contact using alcohol-based hand sanitizers.
- Staff correctly don and doff gowns and gloves prior to entering and exiting patient rooms.
- Dedicated, disposable medical equipment (e.g., stethoscopes, blood pressure cuffs) is used for each patient.
- Environmental services perform daily and terminal cleaning of patient rooms using a standard quaternary ammonium disinfectant.
- No prophylactic antimicrobial or antifungal agents are administered to asymptomatic patients.

Based on current infection control guidelines, which of the following is the most likely root cause of this pathogen's transmission within the unit?

A 74-year-old woman is evaluated in the intensive care unit for a new-onset fever and increased oxygen requirement. She was admitted 5 days ago for a severe ischemic stroke and currently requires mechanical ventilation. Her temperature is 39.1°C (102.4°F), blood pressure is 88/54 mmHg, and heart rate is 118/min. She has a documented history of a severe anaphylactic reaction to penicillin, characterized by hives and airway edema. A portable chest radiograph shows a new right lower lobe consolidation. A tracheal aspirate is sent for Gram stain and culture. Which of the following medications are most appropriate to include in this patient's initial empiric pharmacologic regimen? (Select all that apply)

A 74-year-old man comes to the clinic because of a severely pruritic rash that started two weeks ago. Over the past week, he has developed large, fluid-filled blisters on his lower abdomen, thighs, and forearms. Physical examination reveals multiple tense bullae on an erythematous and urticarial base. The Nikolsky sign is negative. Examination of the oral mucosa shows no erosions or ulcerations. A punch biopsy of the edge of an intact blister and a perilesional skin biopsy for direct immunofluorescence are performed to establish the diagnosis. Which of the following pathologic and immunofluorescence findings are characteristic of this patient's condition? (Select all that apply)

A 42-year-old woman comes to the clinic for a routine follow-up. Eighteen months ago, she underwent a lumpectomy and adjuvant radiation therapy for an estrogen receptor-positive, progesterone receptor-positive, HER2-negative invasive ductal carcinoma of the right breast. She has been taking tamoxifen since completing radiation therapy. Three weeks ago, she visited an urgent care clinic for new-onset anhedonia, persistent low mood, and severe hot flashes that frequently interrupted her sleep. She was diagnosed with major depressive disorder and prescribed fluoxetine. Today, the patient reports a mild improvement in her mood but states the hot flashes remain highly bothersome. Additionally, she expresses concern after reading an article online about potential interactions between her medications. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most appropriate pharmacologic intervention for this patient?

An otherwise healthy 45-year-old female teacher establishes care at a new primary care office. She reports feeling well with no recent changes in weight, bowel habits, temperature tolerance, or energy levels. Vital signs are within normal limits. During the physical examination, the physician palpates a 1.5-cm, firm, mobile, non-tender nodule in the right lobe of the thyroid gland. There is no palpable cervical lymphadenopathy, and the remainder of the examination is unremarkable. Which of the following is the most appropriate next step in the diagnostic workup?

Accompanied by her spouse, a 26-year-old woman arrives at the emergency department complaining of agonizing right-sided lower abdominal pain and severe lightheadedness that commenced roughly two hours prior. Upon initial assessment, she is lethargic and visibly diaphoretic with marked conjunctival pallor. Her last menstrual cycle occurred 7 weeks ago, and she noted a small amount of vaginal bleeding this morning. Vital signs are notable for a temperature of 37.1°C (98.8°F), a blood pressure of 72/40 mm Hg, a heart rate of 138/min, a respiratory rate of 24/min, and an oxygen saturation of 98% breathing ambient air. Abdominal examination demonstrates a rigid, distended contour with generalized tenderness to palpation and involuntary guarding. Her capillary refill time is prolonged at 4 seconds. Which of the following represents the most appropriate initial step in the management of this patient?

Determine the optimal diagnostic sequencing for the following diverse clinical presentations of suspected acute pulmonary embolism. Link each specific patient profile to the most appropriate next step in their diagnostic workup, factoring in hemodynamic stability, pretest probability, and comorbidities.