All practice questions

Neurological physical examination is critical for localizing acute ischemic strokes. Match each constellation of physical examination findings with its most likely corresponding occluded vascular territory.

A physician is managing a 45-year-old female patient who presents with resistant hypertension and spontaneous hypokalemia. Diagnostic testing reveals an elevated plasma aldosterone concentration to plasma renin activity ratio, and abdominal imaging confirms a unilateral adrenal adenoma. The patient's condition results in excessive sodium reabsorption in the distal nephron. Arrange the following cellular events in the correct chronological sequence to describe the physiological mechanism of action for the hormone overproduced in this condition.

A $62$-year-old man comes to the clinic to review the results of a recent imaging study. Two weeks ago, he was evaluated in the emergency department for severe left-sided flank pain radiating to the groin. A non-contrast computed tomography (CT) scan of the abdomen and pelvis demonstrated a $4$-mm left ureteral calculus, which he subsequently passed. The CT scan also incidentally revealed a $3.2$-cm right adrenal nodule. The nodule is well-circumscribed and homogeneous, with an unenhanced attenuation of $8$ Hounsfield units. The patient has no history of malignancy and reports feeling well since passing the stone. Medical history is significant for hypertension and osteoarthritis. His medications include lisinopril, hydrochlorothiazide, and occasional ibuprofen. Blood pressure is $142/88$ mm Hg, pulse is $76$/min, and body mass index is $26$ kg/m $^2$. Physical examination is unremarkable, with no supraclavicular fat pads, abdominal striae, or skin thinning. Serum potassium was $4.1$ mEq/L in the emergency department.

Which of the following is the most appropriate next step in laboratory evaluation?

A 35-year-old woman comes to the clinic reporting progressive fatigue, diffuse muscle weakness, and excessive thirst for the past three weeks. Her medical history is notable for Sjögren syndrome and two episodes of calcium phosphate nephrolithiasis over the past five years. She currently takes no medications. Her temperature is 37.0°C (98.6°F), blood pressure is 110/70 mmHg, pulse is 88/min, and respiratory rate is 16/min. Physical examination reveals dry mucous membranes but is otherwise unremarkable. Laboratory studies are obtained as shown below:

Based on the laboratory data provided, what is the patient's calculated urine osmolar gap? (Enter the numerical value only)

Match each characteristic thoracic imaging finding described below with its most likely associated clinical condition.

A 48-year-old man who recently emigrated from Southeast Asia presents to the clinic complaining of progressive abdominal swelling, bilateral ankle swelling, and generalized fatigue over the past 4 months. He recalls having a chronic cough and night sweats a few years ago that resolved without formal medical treatment. His temperature is $37.1^{\circ}\text{C}$ ($98.8^{\circ}\text{F}$), blood pressure is $118/78\text{ mm Hg}$, and pulse is $88\text{ /min}$. On physical examination, the jugular veins are distended to $11\text{ cm H}_2\text{O}$ while the patient is sitting at a $45^{\circ}$ angle. The jugular venous pressure paradoxically increases during deep inspiration. Careful inspection of the neck veins reveals a rapid, deep $y$ descent. Cardiac auscultation reveals a high-pitched, early diastolic sound heard best at the left sternal border. The lungs are clear to auscultation bilaterally. Abdominal examination demonstrates shifting dullness. Which of the following is the most likely diagnosis?

For each of the following clinical scenarios requiring targeted biologic therapy, select the precise immunopathologic mechanism of the most appropriate therapeutic agent.

A physician is reviewing laboratory results for several patients presenting with microcytic anemia (Mean Corpuscular Volume < 80 fL). Match the following serum iron and hematologic profiles to their most likely diagnostic etiology.

Reference ranges:
Serum iron: 60-170 µg/dL
Total iron-binding capacity (TIBC): 240-450 µg/dL
Ferritin: 15-200 ng/mL
Transferrin saturation: 20-50%
Red Cell Distribution Width (RDW): 11.5-14.5%

A 28-year-old woman is brought to the emergency department by her roommate due to confusion, ringing in her ears, and rapid breathing for the past $6$ hours. She has also had multiple episodes of non-bilious vomiting. The roommate reports finding an empty bottle of over-the-counter pain medication in their shared bathroom. On physical examination, the patient appears agitated and diaphoretic. Vital signs are temperature $37.8^\circ$ C ($100.0^\circ$ F), blood pressure $110/70$ mm Hg, heart rate $112$/min, and respiratory rate $28$/min.

Laboratory studies show:

Serum chemistry
Sodium: $140$ mEq/L
Potassium: $3.4$ mEq/L
Chloride: $96$ mEq/L
Bicarbonate: $14$ mEq/L
Blood urea nitrogen: $20$ mg/dL
Creatinine: $1.2$ mg/dL

Arterial blood gas (room air)
pH: $7.45$
PaCO $_2$: $20$ mm Hg
PaO $_2$: $96$ mm Hg

Which of the following is the most accurate interpretation of this patient's acid-base status?

Match each clinical presentation to the most appropriate initial or confirmatory laboratory test required to establish the diagnosis.

A 68-year-old institutionalized female with advanced Parkinson disease is evaluated in the emergency department for severe abdominal distension and an inability to pass flatus for the past 48 hours. She has experienced intermittent, crampy abdominal pain and two episodes of nonbilious emesis earlier today. Her medical history is significant for chronic constipation, hypertension, and osteoarthritis. Vital signs show a temperature of 37.2°C (99.0°F), heart rate of 110/min, blood pressure of 132/82 mm Hg, and respiratory rate of 18/min. Physical examination reveals a markedly distended, tympanitic abdomen with high-pitched, 'tinkling' bowel sounds. There is diffuse mild tenderness to palpation but no guarding or rebound tenderness. Digital rectal examination demonstrates an empty rectal vault. An upright abdominal radiograph is obtained, which reveals a massively dilated, comma-shaped large bowel loop originating from the right lower quadrant and projecting toward the left upper quadrant. Multiple dilated loops of small bowel with air-fluid levels are also present, with a complete absence of gas in the distal descending colon and rectum. Based on these imaging findings, which of the following is the most appropriate next step in management?

A 47-year-old woman comes to the clinic reporting worsening fatigue, increased thirst, and frequent urination over the past three months. She has a history of chronic cough and was told she had "enlarged lymph nodes" in her chest a year ago, but she did not follow up. Her temperature is 37.0°C (98.6°F), blood pressure is 128/82 mmHg, and pulse is 78/min. Physical examination reveals a few erythematous nodules on her anterior lower legs. Laboratory studies show:

Which of the following cellular mechanisms best explains this patient's current laboratory abnormalities?

A 28-year-old woman, gravida 3, para 1, abortus 1, comes to the clinic for a routine prenatal visit at 11 weeks gestation. She has a healthy 3-year-old child and a history of a spontaneous abortion at 10 weeks gestation last year. Over the past 6 months, she has noticed that her fingers frequently turn pale, then blue, and finally red when exposed to cold weather. She also reports intermittent aching in her wrists and knees, but denies any morning stiffness lasting longer than a few minutes. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mm Hg, pulse 82/min, and respirations 14/min. Physical examination shows no joint swelling, warmth, or erythema. There are no skin rashes, oral ulcers, or alopecia.

Initial laboratory results are as follows:

Hemoglobin: 11.2 g/dL
Leukocyte count: 4,500/mm³
Platelet count: 115,000/mm³
Urinalysis: 1+ protein, no red blood cells or casts

Which of the following is the most appropriate next step in laboratory evaluation?

A 58-year-old man comes to the clinic reporting a two-month history of a persistent left-sided scrotal mass that feels like a 'bag of worms.' The mass does not decrease in size when he lies flat. He also reports intermittent episodes of pink-tinged urine over the past month. His past medical history is significant for a 30-pack-year smoking history, though he quit 5 years ago. His vital signs show a blood pressure of 150/95 mmHg, heart rate 82/min, and a BMI of 28 kg/m2. Physical examination confirms a left-sided varicocele that remains prominent in the supine position. Laboratory testing reveals a hemoglobin of 19.2 g/dL and a hematocrit of 58%. Which of the following best describes the molecular or pathophysiologic mechanism most directly responsible for the laboratory abnormality seen in this patient?

Match the following distinct radiographic descriptions with their most likely underlying clinical condition or pathophysiologic diagnosis.

A 9-year-old boy is brought to the emergency department by his parents due to abdominal pain that began yesterday. The pain initially started around his umbilicus but has since migrated to the right lower quadrant. He has had one episode of nonbilious vomiting and has refused to eat since yesterday morning. His temperature is $38.3^\circ\text{C}$ ($101.0^\circ\text{F}$), blood pressure is $105/65\text{ mm Hg}$, pulse is $110\text{/min}$, and respiratory rate is $18\text{/min}$. Physical examination reveals localized tenderness halfway between the anterior superior iliac spine and the umbilicus, along with involuntary guarding. Laboratory studies demonstrate a leukocyte count of $14,500/\text{mm}^3$ with 82% neutrophils. Which of the following is the most appropriate initial imaging modality to evaluate this patient's condition?

A 62-year-old man comes to the clinic due to a 2-month history of progressive proximal muscle weakness, fatigue, and a 5-kg (11-lb) weight gain. He has a 40-pack-year smoking history. Blood pressure is 168/98 mm Hg, pulse is 88/min, and respirations are 16/min. Physical examination shows central obesity, facial plethora, and violaceous striae over the abdomen. There is 3/5 strength in the proximal muscles of the upper and lower extremities.

Laboratory studies show the following:

Endocrine studies:

A high-dose (8 mg) dexamethasone suppression test is performed. The baseline serum cortisol is 42 µg/dL, and the post-dexamethasone serum cortisol is 40 µg/dL.

Which of the following is the most likely diagnosis?

An emergency medical services team brings a 72-year-old man to the emergency department due to severe, escalating lower back pain and urinary retention over the past 14 hours. The patient reports a heavy, numb sensation in his groin and inner thighs, as well as new-onset difficulty ambulating. His medical history includes hypertension, prostate cancer treated with radiation therapy five years ago, and sick sinus syndrome. For the latter, a non-MRI-conditional permanent dual-chamber pacemaker was placed three weeks ago. Vital signs are within normal limits. On physical examination, there is pronounced focal tenderness over the L4-L5 spinous processes. Neurologic assessment shows 4/5 strength in bilateral ankle dorsiflexion and plantar flexion. Sensation to pinprick is diminished in the perianal and perineal regions. Achilles deep tendon reflexes are absent bilaterally. A bedside bladder ultrasound reveals a post-void residual volume of 850 mL. Which of the following is the most appropriate next step in diagnostic imaging for this patient?

Various hereditary cancer syndromes are characterized by distinct clinical presentations and specific underlying molecular defects. Match each patient's clinical vignette with the fundamental genetic mechanism responsible for their disease pathogenesis.

A 24-year-old man is evaluated in the emergency department for severe, escalating right lower leg pain. Twelve hours ago, he sustained a closed mid-shaft tibial fracture during a rugby match and was treated with closed reduction and application of a long-leg cast. He now complains of unrelenting pain that is not relieved by multiple doses of intravenous morphine. The resident physician examines the patient and documents: "The right foot is warm with a capillary refill time of less than 2 seconds. Both the dorsalis pedis and posterior tibial pulses are 2+ and symmetric to the contralateral side. Acute compartment syndrome is highly unlikely given the intact distal perfusion." The resident plans to admit the patient for pain control and observation. Which of the following physical examination findings is the most sensitive and reliable early indicator of the condition the resident erroneously excluded?