All practice questions

A 45-year-old man is brought to the emergency department actively seizing. His wife reports that he has a history of epilepsy but ran out of his medications last week. The generalized tonic-clonic seizure began 10 minutes ago and has been continuous. He is unresponsive, and his airway is currently patent. Intravenous access is established. Arrange the following pharmacologic interventions in the correct sequential order of administration for escalating management of this patient's condition.

A medical resident is reviewing classic radiologic patterns across various imaging modalities to prepare for independent practice. Match the following pathognomonic imaging findings with their corresponding underlying clinical diagnosis.

A $62$-year-old woman presents to the outpatient cardiology office for evaluation of chest discomfort. Over the past month, she has experienced multiple episodes of a dull, left-sided chest ache that consistently occurs when climbing the two flights of stairs to her apartment. The pain reliably resolves after $5$ minutes of rest. She has a history of type 2 diabetes mellitus, hypertension, and chronic kidney disease stage 4. Her current medications include amlodipine, lisinopril, and insulin glargine.

Vital signs are temperature $36.8^\circ$ C ($98.2^\circ$ F), blood pressure $146/86$ mmHg, heart rate $74$/min, and respiratory rate $14$/min. Physical examination reveals a normal point of maximal impulse, normal $S_1$ and $S_2$, and no murmurs or gallops. Lungs are clear to auscultation. There is no lower extremity edema.

Recent laboratory studies show:

A resting $12$-lead electrocardiogram shows sinus rhythm with a QRS duration of $145$ ms, broad notched R waves in leads I, aVL, $V_5$, and $V_6$, and deep S waves in leads $V_1$ and $V_2$. No prior electrocardiograms are available for comparison.

Which of the following is the most appropriate next step in the diagnostic workup for this patient's chest pain?

A 62-year-old man comes to the clinic due to a 24-hour history of severe pain, redness, and swelling in his right great toe. The pain is so severe that he cannot tolerate the weight of a bedsheet. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, type 2 diabetes mellitus, and stage 4 chronic kidney disease. Current medications include carvedilol, sacubitril-valsartan, empagliflozin, furosemide, and insulin glargine.

Vital signs show a blood pressure of 110/70 mm Hg, heart rate of 68/min, and temperature of 37.1°C (98.8°F). Physical examination reveals an erythematous, warm, swollen, and exquisitely tender right first metatarsophalangeal joint. The jugular venous pressure is estimated at 10 cm H2O. There is 2+ bilateral lower extremity pitting edema.

Laboratory studies show:
Serum creatinine: 2.8 mg/dL (baseline 2.7 mg/dL)
Estimated glomerular filtration rate: 22 mL/min/1.73 m²
Serum uric acid: 9.4 mg/dL

Which of the following is the most appropriate pharmacologic intervention for this patient's current joint symptoms?

A 48-year-old woman presents to the outpatient clinic for evaluation of a newly discovered neck lump. She has felt increasingly anxious over the past month and reports a 4-kg (8.8-lb) weight loss despite a normal appetite. Vital signs include a blood pressure of 132/76 mm Hg and a heart rate of 105/min. Physical examination reveals a firm, mobile, non-tender nodule on the right side of the anterior neck. A targeted bedside diagnostic ultrasound confirms the presence of a 2.5-cm solid, well-circumscribed nodule in the right thyroid lobe, with no suspicious sonographic features and no cervical lymphadenopathy. Laboratory testing reveals a thyroid-stimulating hormone (TSH) concentration of 0.05 $\mu$ U/mL (normal: 0.5–5.0 $\mu$ U/mL) and a free thyroxine (T4) concentration of 2.8 ng/dL (normal: 0.9–1.7 ng/dL).

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

A 54-year-old male is evaluated in the emergency department for severe, progressive lower back pain over the past 48 hours. He notes that the pain now radiates down the posterior aspect of both legs. This morning, he developed numbness between his legs and has been unable to urinate for the past 14 hours. His medical history is significant for ischemic cardiomyopathy, for which he underwent placement of a permanent dual-chamber pacemaker in 2008. Current medications include aspirin, metoprolol, and lisinopril. Vital signs are within normal limits. Physical examination reveals palpable suprapubic fullness. Neurological assessment demonstrates decreased sensation to pinprick over the perineum, perianal region, and medial aspects of both thighs. Ankle dorsiflexion strength is 4/5 bilaterally. Digital rectal examination reveals decreased anal sphincter tone. Bedside ultrasonography of the bladder shows a postvoid residual volume of 800 mL. Which of the following is the most appropriate next imaging study for this patient?

A 32-year-old woman at 24 weeks gestation presents to the emergency department with sudden-onset shortness of breath and pleuritic chest pain. Her heart rate is 115/min, respiratory rate is 24/min, and blood pressure is 110/70 mm Hg. Physical examination reveals mild right leg swelling and tachycardia but normal breath sounds bilaterally. Clinical suspicion for a pulmonary embolism (PE) is high. Arrange the following diagnostic imaging studies and their corresponding findings in the most appropriate chronological sequence for safely and definitively evaluating this patient.

A 32-year-old woman is admitted to the intensive care unit with acute-onset hemoptysis and progressive dyspnea. Over the past three weeks, she has experienced profound fatigue, migratory arthralgias, and a diffuse maculopapular rash on her lower extremities. Her medical history is significant for Graves' disease, which was diagnosed two years ago and has been managed with propylthiouracil and propranolol.

Vital signs include a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure of $145/92\text{ mmHg}$, heart rate of $105/\text{min}$, respiratory rate of $24/\text{min}$, and oxygen saturation of $89\%$ on room air. Physical examination reveals palpable purpuric lesions on the ankles and bilateral crackles in the lung bases.

Laboratory results are as follows:

Urinalysis shows $3+$ blood, $2+$ protein, and numerous dysmorphic red blood cells with red blood cell casts.

Which of the following is the most likely diagnosis?

A 52-year-old man is admitted to the hospital with a two-week history of low-grade fever, fatigue, and generalized joint pain. He has a past medical history of a bicuspid aortic valve. He reports undergoing a root canal procedure four weeks ago without taking prophylactic antibiotics. On examination, his temperature is 38.3°C (100.9°F), pulse is 96/min, and blood pressure is 128/76 mmHg. Cardiovascular examination reveals a new grade 3/6 decrescendo diastolic murmur heard best at the right second intercostal space. Physical exam also shows small, non-tender erythematous macules on his palms. Initial laboratory studies show a mild normocytic anemia and an elevated C-reactive protein. Three sets of blood cultures obtained at admission are growing *Streptococcus mutans*. A transthoracic echocardiogram is performed and demonstrates a thickened bicuspid aortic valve but does not visualize any definite valvular vegetations or abscesses. The patient remains hemodynamically stable. Which of the following is the most appropriate next step in the diagnostic workup?

A 24-year-old woman comes to the clinic reporting a 2-day history of painful urination, increased urinary frequency, and suprapubic discomfort. She has no fever, flank pain, or vaginal discharge. Her medical history is notable for a severe anaphylactic reaction (hives and bronchospasm) to amoxicillin during childhood. Vital signs are within normal limits. Urinalysis is positive for leukocyte esterase and nitrites. Which of the following is the most appropriate empiric pharmacologic intervention for this patient?

A 45-year-old man is brought to the emergency department after a high-speed motorcycle collision. Upon arrival, he is unresponsive with a Glasgow Coma Scale score of 7 (Eye: 1, Verbal: 2, Motor: 4). Vital signs are temperature 36.1°C (97.0°F), blood pressure 68/35 mmHg, pulse 138/min, and respirations 34/min with shallow effort. Pulse oximetry shows 84% on room air. Physical examination reveals a large scalp laceration, tracheal deviation to the left, and absent breath sounds over the right hemithorax. His pelvis crepitates upon gentle lateral compression, and his extremities are cool and mottled.

Arrange the following management steps in the most appropriate sequential order according to standard trauma resuscitation protocols.

A 42-year-old man presents to the clinic for follow-up of severe hypertension. His blood pressure is 172/102 mm Hg despite strict adherence to a daily regimen of maximum-dose extended-release verapamil, hydralazine, and doxazosin. Laboratory studies today reveal a serum potassium level of 2.8 mEq/L, a serum sodium level of 144 mEq/L, and a serum creatinine of 0.9 mg/dL. The patient is otherwise healthy and has no history of licorice ingestion. Primary aldosteronism is strongly suspected.

Assuming all sequential test results yield positive findings and the patient is a candidate for surgical cure, arrange the following diagnostic and pre-procedural steps in the most appropriate, guideline-directed sequence.

Match each patient's clinical presentation with the most appropriate initial or definitive imaging modality to establish the diagnosis.

A 72-year-old man is brought to the emergency department due to the sudden onset of severe, tearing abdominal and back pain that began 30 minutes ago. He has a history of hypertension, hyperlipidemia, and a 5.5-cm abdominal aortic aneurysm (AAA) that has been monitored with annual ultrasounds. His current medications include lisinopril and atorvastatin. On arrival, he is lethargic, pale, and diaphoretic. His temperature is 37.0°C (98.6°F), blood pressure is 72/42 mmHg, heart rate is 128/min, and respiratory rate is 24/min. Physical examination reveals a tender, pulsatile periumbilical mass. Femoral pulses are weak bilaterally. Two large-bore intravenous lines are established. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old man with end-stage renal disease presents to the emergency department with profound, generalized muscle weakness that began earlier today. He missed his last two scheduled hemodialysis sessions due to transportation issues. His blood pressure is 112/68 mmHg, pulse is 54/min, and respirations are 16/min. An electrocardiogram demonstrates absent P waves, a widened QRS complex, and tall, peaked T waves. A point-of-care basic metabolic panel reveals a serum potassium concentration of 8.2 mEq/L.

Arrange the following pharmacologic interventions in the most appropriate chronological sequence of administration for the acute management of this patient's severe hyperkalemia.

A 62-year-old woman is evaluated in the intensive care unit for acute hypoxemic respiratory failure and shock. Five days ago, she underwent a complex open cholecystectomy for gangrenous cholecystitis complicated by a localized abscess. Over the past 12 hours, she developed progressive dyspnea, confusion, and hypotension, requiring endotracheal intubation and initiation of a norepinephrine infusion. She is currently on piperacillin-tazobactam and prophylactic subcutaneous enoxaparin.

Temperature is 38.8°C (101.8°F), heart rate is 125/min, and blood pressure is 85/50 mmHg. Pulse oximetry is 92% on a ventilator setting of FiO2 60% and PEEP 10 cm H2O. Physical examination shows bilateral crackles. Jugular venous pressure is normal. The surgical incision is intact without erythema, but the abdomen is distended and diffusely tender.

Laboratory studies:
- Leukocyte count: 18,500/mm³ (85% neutrophils, 10% bands)
- Hemoglobin: 9.8 g/dL
- Platelets: 85,000/mm³
- Serum creatinine: 2.1 mg/dL (baseline 0.9 mg/dL)
- Serum lactate: 4.2 mmol/L

Chest radiograph reveals new diffuse bilateral alveolar infiltrates with a normal cardiac silhouette and no pleural effusions. Bedside echocardiogram shows a hyperdynamic left ventricle with an ejection fraction of 70% and normal right ventricular size and function.

Order the following differential diagnoses for this patient's acute respiratory and hemodynamic deterioration from most likely (highest pre-test probability) to least likely (lowest pre-test probability).

Emergency medical services bring a 45-year-old female to the trauma bay following a 20-foot fall from scaffolding. Upon arrival, the patient groans in pain and points to her abdomen. Vital signs show a blood pressure of 82/50 mmHg, pulse of 122/min, and respiratory rate of 24/min. Physical evaluation demonstrates marked diffuse abdominal guarding and a visibly deformed left radius. A focused assessment with sonography for trauma (FAST) demonstrates an anechoic collection in the hepatorenal space. A portable pelvic radiograph reveals no abnormalities. Which of the following interventions are indicated immediately? (Select all that apply)

A 42-year-old woman is evaluated in the emergency department for severe palpitations, tremulousness, and anxiety that have worsened over the past week. She has a history of severe, persistent asthma that requires multiple hospitalizations each year and daily use of high-dose inhaled budesonide and formoterol. She is diaphoretic and appears anxious. Her temperature is $37.8^\circ\text{C}$ ($100^\circ\text{F}$), blood pressure is $142/78\text{ mmHg}$, pulse is $122\text{ /min}$, and respirations are $20\text{ /min}$. A fine tremor is noted in her outstretched hands. An electrocardiogram reveals sinus tachycardia at $122\text{ /min}$ with no ischemic changes. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $<0.01\text{ mIU/L}$ and a significantly elevated free T4 level. Which of the following is the most appropriate initial pharmacologic intervention to rapidly control this patient's heart rate?

An internal medicine physician is reviewing chest computed tomography (CT) and radiographic patterns of various pulmonary diseases. Accurate interpretation of these imaging findings is essential for guiding subsequent diagnostic testing and empiric therapies. Match the following classic thoracic imaging findings with their most likely clinical diagnosis.

A 52-year-old woman is evaluated in the clinic following an abnormal screening mammogram that revealed a new, 1.5-cm cluster of pleomorphic microcalcifications in the upper outer quadrant of her right breast. She has no palpable breast masses, skin changes, or axillary lymphadenopathy on physical examination. A stereotactic core needle biopsy is performed.

Histopathologic evaluation of the biopsy specimens demonstrates markedly expanded terminal duct lobular units filled with a solid proliferation of atypical, monomorphic epithelial cells displaying high-grade nuclear atypia. The central portions of these involved spaces show extensive cellular necrosis accompanied by dystrophic calcifications. Immunohistochemical staining for p63 and smooth muscle myosin heavy chain (SMMHC) demonstrates a continuous, intact layer of cells surrounding the periphery of all the involved spaces.

Based on the histopathologic and immunohistochemical findings, which of the following is the most accurate diagnosis?