All practice questions

A 38-year-old patient is admitted to the diagnostic evaluation unit for recurrent episodes of diaphoresis, palpitations, and confusion that resolve rapidly with carbohydrate intake. A supervised 72-hour fasting test is initiated, and comprehensive laboratory studies are drawn when the patient develops symptomatic hypoglycemia (capillary blood glucose 42 mg/dL). Match each distinct laboratory profile below with its most likely underlying pathophysiologic mechanism.

A 45-year-old woman is diagnosed with Zollinger-Ellison syndrome after presenting with chronic diarrhea and recurrent, medically refractory peptic ulcers. Her fasting serum gastrin level is 2,400 pg/mL (normal: < 100 pg/mL) while off proton pump inhibitors, and her gastric fluid pH is 1.5. A secretin stimulation test demonstrates a paradoxical rise in serum gastrin of 350 pg/mL. An initial multiphase contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis performed at a community hospital reveals no discrete pancreatic or hepatic masses. She is referred to a tertiary care center for surgical evaluation.

Arrange the following advanced imaging and localization modalities in the most appropriate chronological sequence to pinpoint the location of the primary neuroendocrine tumor.

Match the following thyroid laboratory profiles to their most likely diagnostic etiology.

Reference Ranges:
TSH: $0.4-4.0$ $\mu$ U/mL
Free T4: $0.9-2.4$ ng/dL
Total T3: $80-200$ ng/dL
24-hour Radioactive Iodine Uptake (RAIU): $10-30\%$

A $41$-year-old woman comes to the primary care clinic for evaluation of joint pain and stiffness that began gradually over the past $3$ months. She reports that the pain primarily affects her wrists and fingers on both hands. The stiffness is most pronounced upon awakening and typically takes about $2$ hours to improve. She feels generally fatigued but denies fevers, weight loss, or skin rashes. Her vital signs are within normal limits. Physical examination demonstrates boggy swelling, warmth, and tenderness of the second and third metacarpophalangeal and proximal interphalangeal joints bilaterally. There is no erythema or joint deformity. A routine complete blood count obtained last week for a wellness visit showed a hemoglobin level of $11.2 \text{ g/dL}$ and a mean corpuscular volume of $88 \text{ fL}$. Which of the following is the most appropriate next step in the diagnostic workup?

An occupational health clinic evaluates a 38-year-old right-handed carpenter who reports chronic right forearm pain and hand numbness. The symptoms began approximately three months ago. He describes an aching discomfort in the proximal, anterior aspect of his forearm that worsens after extensive use of screwdrivers and heavy hand tools. He also notes tingling in his thumb, index finger, and middle finger. Unlike a colleague who recently underwent surgery for similar hand symptoms, the patient specifically denies being awakened from sleep by the pain. On physical examination, provocative testing with maximum passive wrist flexion (Phalen test) and tapping over the volar carpal ligament (Tinel sign) fail to reproduce the symptoms. However, resisted pronation of the forearm exacerbates the aching pain. Based on the most likely diagnosis, which of the following physical examination findings would distinguish this patient's condition from median nerve entrapment at the transverse carpal ligament?

A 42-year-old man presents to the hospital with a 2-day history of low-grade fever, malaise, decreased urine output, and allograft tenderness. He underwent a deceased-donor kidney transplantation 2 months ago. His current medications include tacrolimus, mycophenolate mofetil, and prednisone. His serum creatinine has abruptly increased from a baseline of $1.3 \text{ mg/dL}$ to $2.9 \text{ mg/dL}$. Initial laboratory studies show a subtherapeutic serum tacrolimus trough level. Urinalysis reveals mild proteinuria but is negative for infection.

Arrange the following steps in the most appropriate sequence for the continued evaluation and management of this patient's allograft dysfunction, from initial structural evaluation to the escalation of therapy for refractory immunologic disease.

A $62$-year-old postmenopausal woman is evaluated in the clinic after a routine comprehensive metabolic panel revealed an incidentally elevated serum total calcium of $11.5 \text{ mg/dL}$. She has a remote history of nephrolithiasis but currently feels well. She takes no medications and does not use over-the-counter supplements. The physician initiates a stepwise diagnostic and pre-operative evaluation pathway.

Arrange the following diagnostic evaluations in the most appropriate, evidence-based sequential order to establish the definitive etiology and complete the pre-operative workup.

A $66$-year-old man presents to the internal medicine clinic for a routine health maintenance visit. He reports a six-month history of mild urinary urgency, frequency, and nocturia, but denies any weight loss, bone pain, hematuria, or dysuria. He has no significant past medical history. Examination reveals a slightly enlarged, firm, and asymmetric prostate. As part of a comprehensive evaluation for a potential neoplastic process of the prostate, the physician considers the appropriate diagnostic and therapeutic algorithm.

Arrange the following diagnostic and management steps in the most appropriate chronological order according to current oncologic guidelines.

A 72-year-old woman is brought to the emergency department by emergency medical services. Her family reports that she was last seen in her normal state of health at 10:00 PM the previous night. She awoke at 6:00 AM today with profound left-sided hemiparesis, rightward gaze deviation, and severe dysarthria. Her current blood pressure is 170/90 mmHg, and point-of-care blood glucose is 110 mg/dL. The institutional acute stroke code is activated. Arrange the following neuroimaging modalities in the standard step-wise sequence to evaluate this patient's eligibility for and to execute endovascular reperfusion therapy.

An outpatient evaluation is conducted for a 26-year-old female who reports a lifelong history of recurrent epistaxis and menorrhagia. Her menstrual periods typically last $8$ to $10$ days and require changing a highly absorbent pad every $2$ hours. One month ago, she required suturing and localized thrombin application for persistent oozing following a routine dental extraction. The patient takes an oral contraceptive pill and an over-the-counter iron supplement. Family history is notable for a mother who underwent a hysterectomy at age $40$ for heavy uterine bleeding.

Vital signs are normal. Physical examination reveals scattered, small ecchymoses on the shins but is otherwise unremarkable; there are no petechiae or joint effusions.

Initial laboratory studies reveal:
Complete blood count:
Hemoglobin: $10.8 \text{ g/dL}$
Mean corpuscular volume: $76 \text{ fL}$
Platelet count: $285,000 /\mu\text{L}$

Coagulation profile:
Prothrombin time (PT): $12.5 \text{ seconds}$ (Reference: $11-15 \text{ seconds}$)
Activated partial thromboplastin time (aPTT): $52 \text{ seconds}$ (Reference: $25-40 \text{ seconds}$)
aPTT mixing study (1:1 with normal plasma): $31 \text{ seconds}$

Further hemostatic testing:
Platelet Function Analyzer (PFA-100) closure times:
Collagen/Epinephrine: $185 \text{ seconds}$ (Reference: $84-160 \text{ seconds}$)
Collagen/ADP: $142 \text{ seconds}$ (Reference: $68-121 \text{ seconds}$)
Factor VIII activity: $35\%$ (Reference: $50-150\%$)

Based on the interpretation of these laboratory findings, which of the following is the most likely diagnosis?

A 62-year-old woman is evaluated in the gastroenterology clinic for progressive fatigue, lower extremity paresthesias, and a burning sensation in her tongue. Laboratory testing reveals a hemoglobin level of 9.2 g/dL and a mean corpuscular volume of 114 fL. An upper gastrointestinal endoscopy is performed, revealing a thinned, featureless mucosa in the gastric body and fundus, with preservation of the normal rugal architecture in the gastric antrum. Random biopsies are obtained. The synoptic pathology report indicates the following:

Gastric body and fundus: Marked loss of specialized oxyntic glands with extensive replacement by intestinal-type epithelium containing goblet cells. The lamina propria contains a dense lymphoplasmacytic inflammatory infiltrate. Immunohistochemical staining for chromogranin A demonstrates nodular hyperplasia of neuroendocrine cells.

Gastric antrum: Unremarkable foveolar epithelium and mucinous glands. No acute inflammation is present, and immunostains for *Helicobacter* species are negative.

Which of the following is the most likely diagnosis based on these clinicopathologic findings?

A 32-year-old woman is evaluated for a 6-month history of fatigue, loose stools, and an intensely pruritic, vesicular rash symmetrically distributed over her elbows and knees. Laboratory studies reveal a microcytic anemia, and serologic testing is markedly positive for anti-tissue transglutaminase IgA antibodies. The patient subsequently undergoes an esophagogastroduodenoscopy with biopsy of the distal duodenum, as well as a punch biopsy of perilesional skin. Which of the following histopathologic and immunofluorescence findings are most likely to be present in this patient's biopsy specimens? (Select all that apply)

A group of medical residents is reviewing classic abdominal physical examination findings and their underlying pathophysiological or anatomic mechanisms. Match each eponymous physical examination sign with the mechanism that best explains its clinical presentation.

A 62-year-old man comes to the clinic for a routine follow-up. He has a 10-year history of type 2 diabetes mellitus and a history of heart failure with preserved ejection fraction (ejection fraction of $55\%$). His current medications include metformin, lisinopril, and amlodipine. He feels well and reports no shortness of breath, orthopnea, or lower extremity edema. His blood pressure is $128/78 \text{ mm Hg}$, and his pulse is $72/\text{min}$. Physical examination reveals clear lungs bilaterally and no jugular venous distention. Laboratory evaluation shows a hemoglobin A1c of $8.6\%$. The physician considers adding pioglitazone to the patient's regimen to improve glycemic control but decides against it due to the patient's cardiac history. Which of the following best describes the cellular mechanism by which the avoided medication promotes fluid retention?

A previously healthy individual in their early forties presents to the urgent care clinic complaining of sudden-onset, sharp left lower quadrant abdominal pain that started 24 hours ago. The pain is localized and exacerbates with movement. Vital signs are within normal limits, and the patient is afebrile. Physical examination reveals focal tenderness in the left lower quadrant without guarding or rebound tenderness. Laboratory studies, including a complete blood count and basic metabolic panel, are unremarkable. A computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast is performed. The radiologist notes an isolated, 2.5-cm, oval-shaped, fat-attenuating lesion abutting the anterior serosal surface of the sigmoid colon. The lesion features a hyperdense peripheral rim and a central high-attenuation dot. The adjacent colonic wall thickness is normal, and there is no free fluid or significant lymphadenopathy. Based on these imaging findings, which of the following best describes the underlying pathophysiology of this patient's acute presentation?

Match each patient's clinical presentation with the single most appropriate initial or next imaging study to establish the diagnosis.

A $55$-year-old man visits his primary care physician to discuss the results of a recent imaging study. Two days ago, he was evaluated in the emergency department for severe, colicky left flank pain and was diagnosed with a $4$-mm ureteral stone, which he has since passed. The unenhanced computed tomography (CT) scan of the abdomen and pelvis obtained during that visit confirmed the stone but also revealed an incidental $3.4$-cm nodule in the right adrenal gland. The patient has a history of essential hypertension managed with lisinopril and amlodipine. He reports feeling well and denies headaches, palpitations, episodic sweating, or unexplained weight changes. His blood pressure today is $132/82$ mmHg, and his heart rate is $76$/min. The physician reviews the CT scan images and notes that the right adrenal mass is well-circumscribed and homogeneous. A region of interest placed over the mass reveals an attenuation value of $6$ Hounsfield Units (HU). Based on the interpretation of these imaging findings, which of the following is the most appropriate next step in management?

An occupational therapist in her mid-forties establishes care for persistent, generalized itching that is particularly bothersome at night. She also reports progressive exhaustion over the past several months despite getting adequate sleep. Physical examination reveals excoriations on her upper and lower extremities, but there is no scleral icterus, hepatosplenomegaly, or rash. Laboratory studies show a markedly elevated alkaline phosphatase and gamma-glutamyl transferase, with a normal total bilirubin level and mildly elevated aminotransferases. While awaiting an autoantibody panel, a percutaneous liver biopsy is performed to evaluate the etiology of her cholestasis. Microscopic evaluation of the specimen demonstrates a dense portal tract inflammatory infiltrate consisting of lymphocytes and plasma cells that is actively invading and destroying small interlobular bile ducts. Focal, poorly formed non-caseating granulomas are also identified immediately adjacent to the damaged ducts. There is minimal interface hepatitis and no significant parenchymal fibrosis.

Based on the clinicopathologic findings, which of the following is the most accurate diagnosis?

An internist is evaluating a 48-year-old man who reports a 3-month history of persistent nasal crusting, recurrent epistaxis, and migratory arthralgias. Over the past two weeks, the patient has developed a cough that occasionally produces blood-tinged sputum. He has no prior medical history and takes no medications. Vital signs are within normal limits except for a blood pressure of 152/94 mm Hg. Physical examination reveals an ulcerated septal mucosa and a saddle-nose deformity. Laboratory testing shows a blood urea nitrogen of 38 mg/dL and a serum creatinine of 2.6 mg/dL. Urinalysis demonstrates 2+ protein, numerous dysmorphic red blood cells, and red blood cell casts. Which of the following immunopathologic mechanisms is most directly responsible for this patient's renal findings?

A 29-year-old woman, G1P0 at 24 weeks gestation, presents to the emergency department with sudden-onset shortness of breath and right-sided pleuritic chest pain. Her pulse is 112/min, respiratory rate is 24/min, and blood pressure is 110/70 mm Hg. Oxygen saturation is 96% on room air. Physical examination reveals clear lungs bilaterally and no asymmetric leg swelling. An electrocardiogram shows sinus tachycardia. You highly suspect an acute pulmonary embolism (PE).

Assuming each test fails to definitively rule in or rule out the diagnosis (i.e., yielding normal or indeterminate results), arrange the following imaging studies in the most appropriate step-by-step diagnostic sequence according to current evidence-based guidelines for suspected PE in pregnancy.