All practice questions

A $62$-year-old woman is evaluated in the preoperative clinic prior to an elective right hemicolectomy for colon cancer scheduled in one week. Her medical history is significant for a mechanical mitral valve replacement performed $5$ years ago, paroxysmal atrial fibrillation, and essential hypertension. Her current medications include warfarin, metoprolol, and lisinopril. She reports excellent medication compliance and denies any recent dyspnea, orthopnea, chest pain, or palpitations. Her vital signs are within normal limits. Physical examination shows a well-healed median sternotomy scar and a crisp mechanical heart valve click without murmurs. Her lungs are clear to auscultation. Recent laboratory results show an International Normalized Ratio (INR) of $3.2$. Which of the following perioperative management steps are indicated for this patient? (Select all that apply.)

A 35-year-old woman presents to the clinic reporting progressive weight gain, easy bruising, and proximal muscle weakness over the past eight months. She also notes new-onset facial hair growth and irregular menstrual cycles. Her blood pressure is 158/96 mmHg, and her body mass index is 34 kg/m². Physical examination is notable for facial plethora, a dorsocervical fat pad, and wide, violaceous striae over her lower abdomen. The physician suspects an endogenous hypercortisolism syndrome.

Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's condition, starting from the initial screening investigation to the most definitive preoperative localization test.

A 56-year-old man with a history of alcohol-related cirrhosis presents to the hepatology clinic with newly developed, progressive abdominal distension. An in-office ultrasound confirms moderate ascites without hepatic vein thrombosis. The patient is hemodynamically stable, denies abdominal pain or fever, and has normal renal function. Arrange the following steps in the most appropriate chronological sequence for the evaluation, step-wise management, and long-term monitoring of this patient's new-onset ascites.

A $28$-year-old male construction worker is brought to the emergency department after falling approximately $6$ meters ($20$ feet) from scaffolding. He landed directly on his head and upper back. Emergency medical services placed him in a rigid cervical collar and on a long backboard. Upon arrival, the patient is awake and alert, reporting severe posterior neck pain and an inability to move his arms or legs.

Vital signs are:
Temperature: $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$)
Blood pressure: $74/42\text{ mmHg}$
Heart rate: $48\text{/min}$
Respiratory rate: $10\text{/min}$ with shallow, abdominal breathing
Oxygen saturation: $87\%$ on room air

Physical examination reveals flaccid paralysis, absent deep tendon reflexes, and loss of pain and temperature sensation below the level of the clavicles. His extremities are remarkably warm and flushed.

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

A $54$-year-old man with a history of chronic alcohol use disorder and severe malnutrition is brought to the emergency department after a witnessed generalized tonic-clonic seizure. On arrival, he is postictal. Initial laboratory studies reveal a serum sodium concentration of $104 \text{ mEq/L}$. He is promptly treated with two $100 \text{ mL}$ intravenous boluses of $3\%$ sodium chloride, which aborts any further clinical seizure activity. He is transferred to the intensive care unit, and a continuous infusion of $0.9\%$ sodium chloride is initiated.

Six hours later, the patient is awake and oriented to person and place. Repeat laboratory studies show a serum sodium concentration of $115 \text{ mEq/L}$. Over the past two hours, the patient's urine output has increased to $600 \text{ mL/hour}$. A spot urine osmolality is $85 \text{ mOsm/kg}$.

Which of the following is the most appropriate next step in the management of this patient's fluid and electrolyte status?

A 62-year-old man with a history of type 2 diabetes mellitus and stage 4 chronic kidney disease presents to the emergency department with severe generalized muscle weakness and tingling in his extremities that began earlier today. His home medications include lisinopril, amlodipine, and sitagliptin. His heart rate is 54/min, blood pressure is 112/68 mmHg, and respiratory rate is 18/min. A 12-lead electrocardiogram demonstrates peaked T waves, absent P waves, and a widened QRS complex. A point-of-care basic metabolic panel reveals a serum potassium level of 7.8 mEq/L. The physician decides to immediately begin pharmacologic management.

Arrange the following pharmacologic interventions in the most appropriate sequential order of priority for this patient's acute management.

A 32-year-old woman comes to the outpatient clinic reporting a 6-week history of intermittent double vision and drooping of her right eyelid. She notes that these symptoms are usually absent in the morning but become progressively more noticeable by the late afternoon and evening. Recently, she has also experienced mild difficulty chewing tough foods like steak. She has no significant past medical history and takes no medications. Vital signs are within normal limits. Neurologic examination reveals a right-sided ptosis that becomes more pronounced after the patient is asked to maintain an upward gaze for 60 seconds. Extraocular movements are notable for asymmetric limitation in both eyes, without pupillary involvement. Strength in the proximal and distal extremities is intact, and deep tendon reflexes are normal bilaterally. Which of the following is the most appropriate next step in the diagnostic evaluation?

Determine the most appropriate post-discharge care environment for each of the following complex clinical presentations based on the patient's medical stability, rehabilitation endurance, and symptom management requirements.

An internist evaluates a 66-year-old female patient who recently relocated to the area and wants to establish primary care. She has an intact uterus and cervix. She provides comprehensive medical records from her previous provider. Review of these records shows negative cervical cytology and human papillomavirus (HPV) co-testing at ages 55, 60, and 64. She has never had an abnormal Papanicolaou test or a history of cervical dysplasia. She is currently sexually active with her husband of 40 years. Which of the following is the most appropriate next step regarding cervical cancer screening for this patient?

A 24-year-old woman is brought to the emergency department by ambulance due to severe shortness of breath, wheezing, and a tight chest that began 2 hours ago. She has a history of moderate persistent asthma but has not used her inhalers for the past week. On arrival, she appears anxious and is using accessory muscles of respiration. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $135/85\text{ mm Hg}$, pulse is $118/\text{min}$, and respiratory rate is $28/\text{min}$. Oxygen saturation is $92\%$ on room air. Physical examination reveals diffuse bilateral end-expiratory and inspiratory wheezes. Laboratory studies show a leukocyte count of $12,500/\text{mm}^3$ with a normal differential. Which of the following pharmacologic interventions should be administered as part of her immediate initial management? (Select all that apply)

A 32-year-old woman, gravida 3, para 3, is evaluated on the labor and delivery unit for excessive vaginal bleeding 20 minutes after a spontaneous vaginal delivery of a 4200-g (9.3-lb) neonate. The placenta was delivered intact 5 minutes after the neonate. Her past medical history is significant for chronic hypertension and moderate persistent asthma. Current medications include oral nifedipine and a budesonide-formoterol inhaler. Her blood pressure is 168/105 mmHg, and heart rate is 112/min. Physical examination reveals a large gush of blood from the vagina. The uterus is soft, boggy, and palpable 3 cm above the umbilicus. Careful inspection of the vagina and cervix reveals no lacerations. Bimanual uterine massage is initiated, and a continuous intravenous oxytocin infusion is started. Ten minutes later, the patient continues to have heavy vaginal bleeding, and the uterus remains boggy. Which of the following is the most appropriate next pharmacologic intervention?

A 58-year-old man is evaluated in the intensive care unit for sudden hemodynamic decompensation. He was admitted three days ago for severe community-acquired pneumonia and was subsequently intubated due to acute respiratory distress syndrome. His past medical history is significant for chronic obstructive pulmonary disease and hypertension. The patient is currently receiving mechanical ventilation with a high positive end-expiratory pressure. Over the last 5 minutes, the ventilator has been repeatedly alarming for high peak airway pressures. His temperature is 37.8°C (100.0°F), blood pressure is 72/40 mm Hg, pulse is 142/min, and respiratory rate is 28/min (set ventilator rate 18/min). Pulse oximetry shows an oxygen saturation of 83%. Physical examination reveals distended neck veins and a trachea that is deviated to the right. Auscultation demonstrates markedly diminished breath sounds over the left hemithorax with hyperresonance to percussion. Which of the following is the most urgent initial step in the management of this patient?

An executive in her late twenties visits the ambulatory care clinic reporting six months of progressively worsening shortness of breath with physical exertion. She denies chronic cough, orthopnea, daytime fatigue, or prior lung disease. She has no significant medical history and takes only oral contraceptives. Vital signs are within normal limits, with an oxygen saturation of $96\%$ on ambient air. Physical examination reveals a prominent pulmonic component of the second heart sound and a faint parasternal heave. The lung fields are clear to auscultation, and there is no peripheral edema. Electrocardiography reveals right axis deviation and an incomplete right bundle branch block. A chest radiograph demonstrates prominent central pulmonary arteries without parenchymal infiltrates. Echocardiography shows a structurally normal left ventricle with an ejection fraction of $65\%$, normal valvular function, and right ventricular enlargement with an estimated right ventricular systolic pressure of $52$ mmHg. Pulmonary function testing demonstrates a normal forced vital capacity, normal FEV1/FVC ratio, and a slightly reduced diffusion capacity for carbon monoxide (DLCO). Which of the following is the most appropriate next step in evaluating this patient's condition?

A 74-year-old woman is brought to the emergency department by emergency medical services after a witnessed generalized tonic-clonic seizure lasting 2 minutes. She is currently postictal, profoundly confused, and agitated. Her past medical history is significant for atrial fibrillation, major depressive disorder, diabetic peripheral neuropathy, and hypertension. Her home medications include apixaban, amitriptyline, fluoxetine, and metoprolol succinate. Her husband notes that she was recently prescribed tramadol for acute back pain and took her first two doses earlier today.

Vital signs are:
Temperature: 39.4°C (102.9°F)
Heart rate: 142/min
Blood pressure: 175/95 mm Hg
Respiratory rate: 22/min
SpO2: 96% on room air

Physical examination reveals a profusely diaphoretic and flushed woman. Pupils are 6 mm bilaterally and reactive to light. Bowel sounds are hyperactive. Neuromuscular examination is remarkable for significant hypertonia in the lower extremities, 4+ patellar reflexes bilaterally, and spontaneous, sustained ankle clonus.

An electrocardiogram demonstrates atrial fibrillation with a rapid ventricular response of 142/min and a QTc interval of 535 ms.

Which of the following pharmacologic interventions are indicated in the immediate management of this patient? (Select all that apply)

A 58-year-old man is evaluated on the medical-surgical ward for transition of care. He was admitted 8 days ago for a severe right diabetic foot infection complicated by osteomyelitis of the first metatarsal. He underwent a partial ray amputation on hospital day 2. The surgical site was intentionally left open and currently requires complex wet-to-dry dressing changes twice daily. He is receiving intravenous vancomycin via a peripherally inserted central catheter (PICC) for methicillin-resistant Staphylococcus aureus (MRSA); the planned antibiotic course is 6 weeks.

Vital signs are normal, and he is afebrile. Laboratory studies show a leukocyte count of $7,800/\mu L$ and a C-reactive protein (CRP) of $35 \text{ mg/L}$ (normal: $<10 \text{ mg/L}$), which has steadily decreased from $150 \text{ mg/L}$ on admission.

From a mobility standpoint, the patient is strictly non-weight-bearing on the right lower extremity. Physical therapy has trained him to be independent with wheelchair mobility on level surfaces; however, he cannot use crutches or a walker due to pre-existing severe bilateral shoulder osteoarthritis. He lives alone in a second-floor apartment accessible only by a steep flight of stairs. He is clinically stable and eager to leave the acute care hospital.

Which of the following is the most appropriate next step in the disposition of this patient?

A $58$-year-old man is admitted to the hospital with a $4$-day history of progressively worsening left lower quadrant abdominal pain, subjective fever, and reduced appetite. His past medical history is significant for hypertension and hyperlipidemia. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $118/74\text{ mmHg}$, pulse is $106/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals a non-distended abdomen with marked tenderness and guarding in the left lower quadrant. There is no diffuse rebound tenderness or rigidity. Bowel sounds are hypoactive. Laboratory evaluation shows a leukocyte count of $16,500/\text{mm}^3$ with $82\%$ neutrophils. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated. Cross-sectional imaging of the abdomen and pelvis with intravenous contrast reveals severe wall thickening of the sigmoid colon with surrounding fat stranding, as well as an adjacent, well-circumscribed $6.5\text{-cm}$ fluid collection with rim enhancement. There is no evidence of free air in the peritoneal cavity.

Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of suspected gastrointestinal bleeding with the most appropriate next diagnostic test in the sequencing algorithm.

A 65-year-old male presents to the clinic for a routine health maintenance examination. He has not seen a physician in over a decade. He feels well and has no acute complaints. His medical history is unremarkable, and he takes no medications. He has a 40-pack-year history of smoking and continues to smoke one pack of cigarettes daily. Vital signs are within normal limits, and physical examination is unremarkable. Which of the following preventive screening tests are indicated for this patient? (Select all that apply)

A $35$-year-old woman is brought to the emergency department by paramedics after being struck by a speeding delivery truck while walking in a crosswalk. Upon arrival in the trauma bay, she is unresponsive to verbal commands and only groans in response to painful stimuli.

Her vital signs are:
Temperature: $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$)
Heart rate: $138/\text{min}$
Blood pressure: $72/40 \text{ mmHg}$
Respiratory rate: $32/\text{min}$
Oxygen saturation: $84\%$ on room air

Physical examination reveals a massive, actively spurting laceration over the right anteromedial thigh. The right lower extremity is deformed. Breath sounds are present and symmetric bilaterally. The abdomen is grossly distended and tense.

Arrange the following initial management steps in the most appropriate chronological order according to advanced trauma life support protocols.

A 35-year-old woman is brought to the emergency department immediately after accidentally ingesting a meal containing peanuts. She is in marked respiratory distress with audible stridor and diffuse urticaria. Her blood pressure is 75/40 mm Hg, heart rate is 135/min, and oxygen saturation is 91% on room air. Arrange the following pharmacologic interventions in the correct sequence of prioritization for the initial stabilization of this patient, from the most immediate life-saving intervention to adjunctive therapy.