Cardiology
A 55-year-old man presents to the emergency department with crushing substernal chest pain radiating to his left arm. His ECG shows ST-segment elevation in leads V1-V4. Which of the following is the most appropriate next step in management?
A. Administer aspirin and send for an emergent coronary angiography
B. Administer thrombolytic therapy
C. Start a beta-blocker and observe
D. Administer nitroglycerin and morphine
E. Order a chest X-ray
Answer: A. Administer aspirin and send for an emergent coronary angiography
Explanation: The patient’s presentation is consistent with an acute anterior myocardial infarction (MI), indicated by ST-segment elevations in leads V1-V4. The most appropriate next step is to administer aspirin and send the patient for emergent coronary angiography to restore blood flow.
A 70-year-old man with a history of heart failure presents with sudden onset shortness of breath and frothy pink sputum. His chest X-ray shows bilateral pulmonary infiltrates. What is the most likely diagnosis?
A. Acute respiratory distress syndrome (ARDS)
B. Pneumonia
C. Pulmonary embolism
D. Acute pulmonary edema
E. Interstitial lung disease
Answer: D. Acute pulmonary edema
Explanation: The sudden onset of dyspnea and frothy pink sputum, along with bilateral pulmonary infiltrates on chest X-ray, is suggestive of acute pulmonary edema, often seen in heart failure exacerbations.
A 35-year-old man presents with recurrent episodes of hematuria and flank pain. A CT scan reveals multiple renal cysts. What is the most likely diagnosis?
A. Acute pyelonephritis
B. Renal cell carcinoma
C. Polycystic kidney disease
D. Hydronephrosis
E. Glomerulonephritis
Answer: C. Polycystic kidney disease
Explanation: The recurrent episodes of hematuria and flank pain, along with multiple renal cysts on CT scan, are characteristic of polycystic kidney disease.
A 25-year-old woman presents with dysuria, increased urinary frequency, and suprapubic pain. Her urinalysis shows pyuria and bacteriuria. What is the most likely diagnosis?
A. Pyelonephritis
B. Interstitial cystitis
C. Urinary tract infection (UTI)
D. Renal stone
E. Vaginitis
Answer: C. Urinary tract infection (UTI)
Explanation: The symptoms of dysuria, increased urinary frequency, and suprapubic pain, along with pyuria and bacteriuria on urinalysis, are indicative of a urinary tract infection (UTI).
You are called to evaluate a 65-year-old man with a history of heart failure who is experiencing increased shortness of breath and bilateral leg swelling. His oxygen saturation is 88% on room air. What is the next best step in management?
A. Administer furosemide IV
B. Start IV fluids
C. Administer a beta-blocker
D. Order a chest X-ray
E. Initiate non-invasive positive pressure ventilation (NIPPV)
Answer: A. Administer furosemide IV
Explanation: The patient’s symptoms are consistent with heart failure exacerbation. IV furosemide (a diuretic) is appropriate to reduce fluid overload.
A 68-year-old woman with a history of hypertension and diabetes presents with sudden onset dyspnea and orthopnea. Her blood pressure is 180/100 mm Hg, and her heart rate is 110 bpm. Auscultation reveals crackles in both lung bases and an S3 gallop. Which of the following is the most likely diagnosis?
A. Pulmonary embolism
B. Acute decompensated heart failure
C. Chronic obstructive pulmonary disease (COPD) exacerbation
D. Acute myocardial infarction
E. Aortic dissection
Answer: B. Acute decompensated heart failure
Explanation: The patient’s symptoms of dyspnea, orthopnea, crackles, and an S3 gallop are classic signs of acute decompensated heart failure, often precipitated by hypertension and diabetes.
Question 5:
A 60-year-old man with a history of chronic bronchitis presents with fever, chills, and productive cough. His chest X-ray shows a right lower lobe infiltrate. What is the most likely diagnosis?
A. Tuberculosis
B. Pneumonia
C. Pulmonary embolism
D. Lung abscess
E. Bronchiectasis
Answer: B. Pneumonia
Explanation: The patient’s symptoms and chest X-ray findings are consistent with pneumonia, which is the most likely diagnosis.
A 55-year-old woman presents with chronic diarrhea, weight loss, and abdominal pain. Her endoscopy reveals villous atrophy in the small intestine. What is the most likely diagnosis?
A. Crohn’s disease
B. Ulcerative colitis
C. Irritable bowel syndrome
D. Celiac disease
E. Lactose intolerance
Answer: D. Celiac disease
Explanation: The chronic diarrhea, weight loss, abdominal pain, and villous atrophy on endoscopy are consistent with celiac disease.
A 55-year-old man presents with fever, chills, and a new heart murmur. Blood cultures are positive for Gram-positive cocci in clusters. What is the most likely diagnosis?
A. Viral endocarditis
B. Fungal endocarditis
C. Bacterial endocarditis
D. Rheumatic fever
E. Nonbacterial thrombotic endocarditis
Answer: C. Bacterial endocarditis
Explanation: The presence of fever, chills, a new heart murmur, and blood cultures positive for Gram-positive cocci in clusters (likely Staphylococcus aureus) indicates bacterial endocarditis.
A nurse calls you about a 55-year-old woman with a history of chronic kidney disease who reports severe generalized weakness. Her lab results show a potassium level of 6.8 mEq/L. What is the most appropriate initial treatment?
A. Administer IV calcium gluconate
B. Give oral sodium polystyrene sulfonate
C. Start IV furosemide
D. Administer sodium bicarbonate
E. Initiate hemodialysis
Answer: A. Administer IV calcium gluconate
Explanation: The first step in managing severe hyperkalemia is to stabilize the cardiac membrane with IV calcium gluconate.
A 60-year-old man with known coronary artery disease presents with palpitations. His ECG shows a regular, narrow-complex tachycardia at a rate of 150 bpm with no visible P waves. Which of the following is the most likely diagnosis?
A. Atrial fibrillation
B. Atrial flutter
C. Paroxysmal supraventricular tachycardia (PSVT)
D. Ventricular tachycardia
E. Sinus tachycardia
Answer: C. Paroxysmal supraventricular tachycardia (PSVT)
Explanation: The presentation of a regular, narrow-complex tachycardia at a rate of 150 bpm with no visible P waves is suggestive of PSVT.
A 65-year-old woman with a history of COPD presents with increased dyspnea, cough, and purulent sputum production. Her arterial blood gas shows a pH of 7.30, PaCO2 of 55 mm Hg, and PaO2 of 60 mm Hg. Which of the following is the most appropriate next step in management?
A. Administer bronchodilators and antibiotics
B. Start non-invasive positive pressure ventilation (NIPPV)
C. Initiate mechanical ventilation
D. Provide supplemental oxygen and observe
E. Administer systemic corticosteroids
Answer: B. Start non-invasive positive pressure ventilation (NIPPV)
Explanation: The patient’s presentation and ABG findings are consistent with an acute exacerbation of COPD with respiratory acidosis. NIPPV is the most appropriate initial intervention to improve ventilation and oxygenation.
A 50-year-old woman presents with right upper quadrant pain, fever, and jaundice. Her liver function tests show elevated bilirubin and alkaline phosphatase levels. What is the most likely diagnosis?
A. Acute pancreatitis
B. Acute cholecystitis
C. Choledocholithiasis
D. Hepatitis
E. Cirrhosis
Answer: C. Choledocholithiasis
Explanation: The combination of right upper quadrant pain, fever, jaundice, and elevated bilirubin and alkaline phosphatase levels suggests choledocholithiasis, which is the presence of stones in the common bile duct.
A 70-year-old woman with a history of diabetes presents with severe pain, swelling, and erythema in her lower leg. The affected area is warm and tender, with blister formation. What is the most likely diagnosis?
A. Cellulitis
B. Deep vein thrombosis
C. Necrotizing fasciitis
D. Erysipelas
E. Phlebitis
Answer: C. Necrotizing fasciitis
Explanation: Severe pain, swelling, erythema, and blister formation in a diabetic patient raise concern for necrotizing fasciitis, a rapidly progressing soft tissue infection.
You receive a call about a 45-year-old man with a history of type 2 diabetes who has been vomiting for the past 24 hours. His blood sugar is 450 mg/dL, and his blood gas shows a pH of 7.20 and bicarbonate of 12 mEq/L. What is the most appropriate next step in management?
A. Administer IV regular insulin and normal saline
B. Give subcutaneous insulin
C. Start IV sodium bicarbonate
D. Administer antiemetics and observe
E. Provide oral rehydration solution
Answer: A. Administer IV regular insulin and normal saline
Explanation: The patient is likely experiencing diabetic ketoacidosis (DKA). Initial management includes IV regular insulin and fluid resuscitation with normal saline.
A 70-year-old man presents with syncope. His ECG shows a third-degree heart block. What is the most appropriate next step in management?
A. Administer atropine
B. Start a beta-blocker
C. Initiate transcutaneous pacing
D. Give intravenous fluids
E. Observe and monitor
Answer: C. Initiate transcutaneous pacing
Explanation: Third-degree heart block (complete heart block) can lead to significant bradycardia and hemodynamic instability. The most appropriate immediate management is to initiate transcutaneous pacing.
A 55-year-old woman is admitted to the ICU with septic shock. Despite aggressive fluid resuscitation, her blood pressure remains low. Which of the following is the most appropriate next step in management?
A. Start norepinephrine infusion
B. Administer a higher dose of fluids
C. Give a bolus of sodium bicarbonate
D. Initiate dopamine infusion
E. Provide corticosteroids
Answer: A. Start norepinephrine infusion
Explanation: Norepinephrine is the first-line vasopressor for septic shock when patients remain hypotensive despite adequate fluid resuscitation.
A 60-year-old man with a history of chronic kidney disease presents with generalized weakness, edema, and frothy urine. His lab results show hypoalbuminemia, hyperlipidemia, and proteinuria. What is the most likely diagnosis?
A. Nephrotic syndrome
B. Acute tubular necrosis
C. Nephritic syndrome
D. Diabetic nephropathy
E. Hypertensive nephrosclerosis
Answer: A. Nephrotic syndrome
Explanation: The combination of hypoalbuminemia, hyperlipidemia, and proteinuria, along with generalized weakness and edema, is indicative of nephrotic syndrome.
A 60-year-old woman with a history of renal transplantation presents with fever, cough, and shortness of breath. She is on immunosuppressive therapy including tacrolimus and prednisone. Chest CT reveals multiple nodular lesions with surrounding ground-glass opacities (“halo sign”). Bronchoalveolar lavage reveals septate hyphae with acute angle branching. What is the most likely diagnosis?
A. Pneumocystis jirovecii pneumonia
B. Cytomegalovirus pneumonia
C. Invasive pulmonary aspergillosis
D. Cryptococcal pneumonia
E. Histoplasmosis
Answer: C. Invasive pulmonary aspergillosis
Explanation: The presence of multiple nodular lesions with a halo sign on chest CT and septate hyphae with acute angle branching on bronchoalveolar lavage in an immunocompromised patient are indicative of invasive pulmonary aspergillosis, caused by Aspergillus species.
A 62-year-old woman with a history of cirrhosis and esophageal varices presents with hematemesis and hypotension. Her blood pressure is 80/50 mm Hg, heart rate is 120 bpm, and she is diaphoretic. What is the most appropriate initial management?
A. Administer IV proton pump inhibitor and observe
B. Give IV octreotide and start a non-selective beta-blocker
C. Perform endoscopic variceal ligation immediately
D. Administer IV fluids, IV octreotide, and arrange for urgent endoscopy
E. Start a norepinephrine infusion
Answer: D. Administer IV fluids, IV octreotide, and arrange for urgent endoscopy
Explanation: In a patient with cirrhosis presenting with hematemesis and hypotension, initial management should include stabilizing the patient with IV fluids, controlling bleeding with IV octreotide, and preparing for urgent endoscopy for definitive treatment.
A 50-year-old woman with no significant past medical history presents with sharp chest pain that worsens with inspiration and lying flat but improves when sitting up and leaning forward. Her ECG shows diffuse ST-segment elevations and PR-segment depressions. Which of the following is the most likely diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolism
C. Acute pericarditis
D. Aortic dissection
E. Pneumothorax
Answer: C. Acute pericarditis
Explanation: The clinical presentation of sharp chest pain that worsens with inspiration and lying flat, and improves when sitting up and leaning forward, along with ECG findings of diffuse ST-segment elevations and PR-segment depressions, is characteristic of acute pericarditis.
A 45-year-old man with a history of asthma presents to the emergency department with severe shortness of breath, wheezing, and use of accessory muscles. He has not improved with multiple albuterol treatments. What is the next best step in management?
A. Administer intravenous magnesium sulfate
B. Start oral corticosteroids
C. Give a dose of subcutaneous epinephrine
D. Intubate and start mechanical ventilation
E. Provide heliox therapy
Answer: A. Administer intravenous magnesium sulfate
Explanation: In a severe asthma exacerbation not responding to initial treatments, intravenous magnesium sulfate can be used as a bronchodilator to help improve airflow and reduce symptoms.
A 45-year-old man presents with fatigue, pruritus, and jaundice. His lab results show elevated alkaline phosphatase and positive antimitochondrial antibodies. What is the most likely diagnosis?
A. Primary sclerosing cholangitis
B. Autoimmune hepatitis
C. Primary biliary cholangitis
D. Alcoholic liver disease
E. Nonalcoholic steatohepatitis
Answer: C. Primary biliary cholangitis
Explanation: The combination of fatigue, pruritus, jaundice, elevated alkaline phosphatase, and positive antimitochondrial antibodies is indicative of primary biliary cholangitis.
A 50-year-old man with a history of alcohol use disorder presents with fever, productive cough, and weight loss over the past month. He has also experienced night sweats. Physical examination reveals cachexia and decreased breath sounds in the right upper lung. Chest X-ray shows a cavitary lesion in the right upper lobe. Sputum culture grows acid-fast bacilli. Despite appropriate initial treatment with isoniazid, rifampin, pyrazinamide, and ethambutol, the patient’s symptoms do not improve. What is the most likely cause of his persistent symptoms?
A. Drug-resistant tuberculosis
B. Re-infection with a different strain of Mycobacterium tuberculosis
C. Co-infection with non-tuberculous mycobacteria
D. Incorrect dosage of anti-tuberculous medications
E. Development of a lung abscess
Answer: A. Drug-resistant tuberculosis
Explanation: The patient’s lack of improvement despite appropriate initial treatment for tuberculosis, combined with a history of alcohol use disorder (which may lead to noncompliance or malabsorption), raises a strong suspicion for drug-resistant tuberculosis. Multidrug-resistant TB should be considered, and further testing for drug susceptibility is necessary to adjust the treatment regimen accordingly.
A 55-year-old woman with a history of rheumatoid arthritis on chronic corticosteroid therapy presents with fever, cough, and dyspnea. Her chest X-ray shows diffuse interstitial infiltrates. Sputum culture is negative, but her beta-D-glucan level is elevated. What is the most likely diagnosis, and what is the most appropriate next step in management?
A. Bacterial pneumonia; start broad-spectrum antibiotics
B. Pulmonary embolism; initiate anticoagulation
C. Pneumocystis jirovecii pneumonia (PJP); start trimethoprim-sulfamethoxazole and corticosteroids
D. Tuberculosis; start anti-tuberculous therapy
E. Fungal infection; start voriconazole
Answer: C. Pneumocystis jirovecii pneumonia (PJP); start trimethoprim-sulfamethoxazole and corticosteroids
Explanation: The patient’s history of rheumatoid arthritis on chronic corticosteroids, along with fever, cough, dyspnea, diffuse interstitial infiltrates on chest X-ray, and elevated beta-D-glucan level, is highly suggestive of Pneumocystis jirovecii pneumonia (PJP). The appropriate management includes initiating trimethoprim-sulfamethoxazole and corticosteroids.