All practice questions

Match each specific burn or environmental injury presentation with the most appropriate immediate or targeted management step.

A 32-year-old woman is evaluated in the urgent care clinic due to severe nausea, diffuse abdominal discomfort, and a persistent "ringing" sensation in her ears for the past day. She reports a history of chronic lower back pain and admits to taking a large handful of over-the-counter analgesic tablets recently to manage a severe flare-up.

Vital signs show a temperature of 38.1°C (100.6°F), blood pressure of 114/72 mm Hg, pulse of 116/min, and respiratory rate of 28/min. She appears flushed and diaphoretic. Lungs are clear to auscultation.

Laboratory results are as follows:

Which of the following best characterizes this patient's current acid-base disturbance?

A $64$-year-old man with a history of alcohol-related cirrhosis and major depressive disorder is hospitalized for worsening abdominal distension and fever. His home medications include spironolactone, furosemide, lactulose, and citalopram. On admission, his temperature is $38.1$°C ($100.6$°F) and blood pressure is $105/65$ mmHg. Physical examination reveals shifting dullness and trace bilateral pedal edema.

Diagnostic paracentesis yields ascitic fluid with a leukocyte count of $1,100$/mm³ ($85\%$ neutrophils). Arterial blood gas analysis on room air reveals:
pH: $7.29$
pCO $_2$: $29$ mmHg
HCO $_3^-$: $14$ mEq/L

The patient is empirically started on intravenous piperacillin-tazobactam and vancomycin, and he receives intravenous albumin on hospital day 1. On hospital day 3, his temperature has decreased to $37.1$°C ($98.8$°F) and his abdominal pain has resolved. The ascitic fluid culture from admission grows *Escherichia coli* that is resistant to ampicillin but susceptible to ceftriaxone, cefepime, piperacillin-tazobactam, and ciprofloxacin. Blood cultures show no growth.

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

A 34-year-old man with a history of intravenous drug use presents to the emergency department with a 4-day history of high fever, chills, and profound fatigue. His temperature is 39.2°C (102.6°F), blood pressure is 110/65 mm Hg, and heart rate is 112/min. Physical examination reveals a new holosystolic murmur at the left lower sternal border that increases in intensity with inspiration, as well as painless, erythematous macules on his palms.

Arrange the following diagnostic and therapeutic management steps in the most appropriate chronological sequence for this patient.

Match each patient's clinical presentation and laboratory evaluation to the most likely underlying diagnosis or pathophysiologic mechanism.

While rounding in the surgical intensive care unit, a physician is called to the bedside of a $72$-year-old male who has developed abrupt respiratory distress and confusion. The patient underwent an open right hemicolectomy for colon adenocarcinoma three days prior. Until this morning, his recovery was unremarkable. Current vital signs include a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), heart rate of 134/min, respiratory rate of 28/min, and blood pressure of 82/48 mmHg. Pulse oximetry reveals an oxygen saturation of 85% on room air.

Physical examination shows profound diaphoresis and jugular venous distention visible up to the angle of the mandible while sitting at a 45-degree angle. The surgical incision appears clean and intact with no surrounding erythema. Pulmonary ausculation yields clear breath sounds bilaterally without wheezes or crackles. Cardiac auscultation reveals a loud pulmonic component of the second heart sound (P2) and an S3 gallop best heard at the lower left sternal border.

A 12-lead electrocardiogram displays sinus tachycardia with new T-wave inversions in leads V1 through V4 and a rightward shift of the QRS axis. Which of the following is the most appropriate next step in the management of this patient?

A 73-year-old woman is brought to the emergency department at 2:00 AM by ambulance due to severe, worsening shortness of breath. She reports waking up abruptly gasping for air and feeling a tight sensation in her chest. Her medical history includes type 2 diabetes mellitus, hypertension, hyperlipidemia, and a 45-pack-year smoking history. She currently smokes half a pack of cigarettes daily. Temperature is 36.8°C (98.2°F), blood pressure is 178/102 mm Hg, pulse is 114/min, and respirations are 28/min. Pulse oximetry is 85% on room air. The patient is sitting upright on the edge of the stretcher, diaphoretic, and using accessory muscles of respiration. Physical examination reveals a jugular venous pressure estimated at 11 cm $H_2O$. Lung auscultation demonstrates diffuse expiratory wheezes and crackles halfway up both posterior lung fields. Cardiac auscultation reveals a regular tachycardia and a prominent third heart sound ($S_3$). The bilateral lower extremities exhibit 2+ pitting edema extending to the shins. Electrocardiogram shows sinus tachycardia and left ventricular hypertrophy. Which of the following is the most appropriate initial pharmacological management for this patient?

Match each of the following clinical and laboratory profiles with the most likely pathophysiologic diagnosis.

A 26-year-old woman, gravida 1, para 0, presents for a scheduled prenatal visit at 27 weeks gestation. Her last prenatal visit was at 22 weeks. The patient reports urinating more frequently and experiencing a mild, dull ache in her right flank for the past week. She denies dysuria, hematuria, fever, and chills. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $110/68 \text{ mm Hg}$, and pulse $86/\text{min}$. Physical examination shows a gravid uterus consistent with dates and trace bilateral lower extremity edema. There is mild right costovertebral angle tenderness. Fetal heart tones are $145/\text{min}$.

Laboratory results are as follows:
Hemoglobin: $10.8 \text{ g/dL}$
Leukocyte count: $14,500/\text{mm}^3$
Platelets: $175,000/\text{mm}^3$
Serum creatinine: $0.5 \text{ mg/dL}$

Urinalysis:
Protein: Trace
Glucose: $1+$
Leukocyte esterase: Negative
Nitrites: Negative
WBC: $2-3/\text{hpf}$
RBC: $0-1/\text{hpf}$

A transabdominal renal ultrasound demonstrates mild dilation of the right renal pelvis and proximal ureter. The left kidney is normal.

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

A couple brings their 12-week-old infant son to the pediatric clinic because they noticed he breathes rapidly and sweats profusely whenever he nurses. The mother reports that feedings take nearly an hour, yet he often falls asleep exhausted before finishing. He has had no fever, cough, or nasal congestion. Review of his growth chart shows his weight has declined from the 30th percentile at birth to below the 5th percentile today. Vital signs show a temperature of 37.0°C (98.6°F), pulse of 168/min, and respiratory rate of 65/min. Pulse oximetry is 97% on room air. Physical examination reveals a thin infant with mild subcostal retractions and diffuse expiratory wheezes bilaterally. Cardiac auscultation demonstrates a hyperdynamic precordium and a prominent, harsh, grade 3/6 holosystolic murmur best heard at the left lower sternal border. The liver edge is palpable 4 cm below the right costal margin. Which of the following is the most appropriate initial pharmacological management for this patient?

A pediatric cardiology team is reviewing complex hemodynamic profiles and physical examination nuances of congenital heart defects. Carefully analyze the clinical presentations, physical examination findings, and diagnostic results provided. Which of the following best matches each specific clinical scenario with its most accurate underlying pathophysiology and diagnosis?

A $7$-month-old boy is brought to the emergency department due to progressive difficulty breathing and poor feeding over the past $24$ hours. One week ago, he had a mild upper respiratory tract infection that seemingly resolved. Currently, the infant is lethargic and sweating heavily during attempts to feed. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), heart rate of $178/\text{min}$, respiratory rate of $68/\text{min}$, and blood pressure of $65/40 \text{ mmHg}$. Oxygen saturation is $93\%$ on room air. Physical examination reveals marked intercostal retractions. Lung auscultation demonstrates diffuse wheezing and bilateral basilar crackles. Cardiac examination reveals tachycardia, a prominent $S_3$ gallop, and a grade $2/6$ holosystolic murmur at the apex. The liver edge is palpated $4 \text{ cm}$ below the right costal margin. Capillary refill time is $4$ seconds, and peripheral pulses are weak in all extremities. A chest radiograph demonstrates severe cardiomegaly with pulmonary venous congestion. Which of the following is the most appropriate next step in management?

During a mid-winter surge of respiratory illnesses, an $8$-month-old girl is evaluated in the pediatric emergency department for severe difficulty breathing. Her symptoms began three days ago with a runny nose, mild cough, and a maximum temperature of $38.0^\circ\text{C}$ ($100.4^\circ\text{F}$). Today, she became increasingly fussy, had two episodes of post-tussive emesis, and refused her last three bottle feeds. Her medical history is notable for delivery at $35$ weeks gestation and a family history of severe asthma in her father. Vital signs show a heart rate of $165$/min, respiratory rate of $68$/min, and oxygen saturation of $87\%$ on room air. Examination reveals an irritable infant with significant head bobbing, nasal flaring, and subcostal retractions. Lung auscultation is remarkable for a prolonged expiratory phase, diffuse polyphonic wheezing, and coarse bilateral crackles. A chest radiograph shows increased anterior-posterior diameter, flattened hemidiaphragms, and prominent perihilar markings but no focal opacities. Which of the following is the most appropriate next step in management?

Match each pediatric clinical presentation and diagnostic finding to the most likely congenital cardiovascular disorder.

A 4-year-old boy is brought to the emergency department due to a sudden onset of high fever, severe sore throat, and difficulty breathing that began 4 hours ago. He has not received any childhood immunizations due to parental preference. On examination, the patient appears toxic, anxious, and is sitting in a tripod position while drooling. He has marked inspiratory stridor and intercostal retractions. Oxygen saturation is 93% on room air.

Arrange the following steps in the most appropriate chronological order for the management of this patient's condition.

A 32-year-old gravida 3, para 2 woman at 38 weeks gestation is admitted to the labor and delivery unit in active labor. Her prenatal course was uncomplicated. Her temperature is 37.1°C (98.8°F), blood pressure is 122/78 mmHg, and pulse is 84/min. The fetal heart rate baseline is 145/min with moderate variability and no decelerations. A sterile vaginal examination reveals the cervix is 5 cm dilated and 80% effaced, with the fetal vertex at -2 station and bulging amniotic membranes. Shortly after the examination, the patient experiences spontaneous rupture of membranes with a large gush of clear fluid. The continuous fetal monitor immediately records an abrupt decrease in the fetal heart rate to 75/min that does not resolve over the next 3 minutes. A repeat vaginal examination reveals a soft, pulsatile, rope-like mass in the vaginal vault extending past the fetal presenting part. Which of the following is the most appropriate next step in the management of this patient?

A 57-year-old woman is evaluated in the clinic for three weeks of intermittent vaginal spotting. She experienced menopause seven years ago and had no vaginal bleeding until this recent episode. She denies abdominal pain, weight loss, or changes in bowel and bladder habits. Her past medical history is significant only for hypertension, which is well controlled with amlodipine. Her body mass index is 24 kg/m². Vital signs are within normal limits. On pelvic examination, the vulva and vagina appear atrophic. The cervix has no visible lesions, but blood is noted at the external os. Bimanual examination reveals a firm, mobile, non-tender, 8-cm mass in the right adnexa. A transvaginal ultrasound demonstrates an 8.5-cm right ovarian mass with both solid and cystic components. The endometrial stripe thickness is measured at 13 mm. Which of the following is the most appropriate next step in the management of this patient?

Seeking evaluation for worsening fatigue and irregular vaginal bleeding, a 46-year-old woman presents to the gynecology clinic. For the past eight months, her menstrual cycles have become highly unpredictable, varying from $21$ to $45$ days in length. When she does menstruate, the bleeding lasts up to $10$ days and is extremely heavy, often requiring her to use two maxi pads simultaneously. Her previous cycles were regular, occurring every $28$ days. Her medical history includes type 2 diabetes mellitus, obesity, and hypothyroidism. Her current medications are metformin and levothyroxine. Vital signs include a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $135/85 \text{ mmHg}$, and heart rate of $88\text{/min}$. Her BMI is $36 \text{ kg/m}^2$. Pelvic examination demonstrates a normal-appearing cervix; the uterus is normal in size, mobile, and non-tender without palpable adnexal masses. A urine beta-hCG test is negative. Laboratory studies reveal a hemoglobin concentration of $10.1 \text{ g/dL}$.

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

During a busy winter shift at an urgent care clinic, a 15-month-old girl is evaluated for three days of progressive rhinorrhea, mild cough, and a tactile fever. Over the last 12 hours, she has developed noisy breathing and decreased her solid food intake, though she continues to drink liquids from a sippy cup. She was born at 39 weeks gestation and has no significant past medical history. Her temperature is 37.7°C (99.9°F), pulse is 135/min, respirations are 48/min, and blood pressure is 90/55 mm Hg. Pulse oximetry shows 94% on room air. On examination, the patient is well-perfused and interactive. Lung auscultation reveals diffuse bilateral expiratory wheezes, scattered crackles, and mild subcostal retractions. A trial of a nebulized bronchodilator is administered in the clinic, but reassessment 30 minutes later shows no clinical change in her respiratory rate or auscultatory findings. Which of the following is the most appropriate next step in management?

During a routine wellness visit, a $38$-year-old G2P2 patient expresses interest in resuming prescription birth control. She previously used an etonogestrel/ethinyl estradiol vaginal ring for several years without adverse effects, but discontinued it prior to her last pregnancy. She gave birth $8$ months ago and is no longer breastfeeding. She hopes to attempt pregnancy again in approximately $12$ to $18$ months. Her menstrual cycles have resumed but are characterized by severe lower abdominal cramping and heavy bleeding lasting $8$ days, requiring her to change pads every $2$ hours. Medical history is notable for generalized anxiety disorder and tobacco use disorder; she consumes approximately $20$ cigarettes daily. Vital signs include a blood pressure of $146/92$ mmHg and a body mass index of $28 \text{ kg/m}^2$. Pelvic examination is unremarkable, and a urine beta-hCG test is negative. She requests a new prescription for the vaginal ring. Which of the following is the most appropriate contraceptive management for this patient?