All practice questions

A 54-year-old man is hospitalized for fever, chills, and a rapidly expanding area of erythema on his right lower leg. He has a medical history of type 2 diabetes mellitus. On admission, his temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $118/76$ mm Hg, pulse is $102$/min, and respirations are $18$/min. Physical examination reveals a warm, tender, sharply demarcated erythematous plaque on the right calf. Blood cultures are drawn, and the patient is empirically started on intravenous vancomycin and piperacillin-tazobactam.

By hospital day 3, the patient's temperature has normalized, and the leg erythema has significantly receded. The blood cultures drawn on admission return positive for *Staphylococcus aureus* in two out of two bottles. Antimicrobial susceptibility testing demonstrates that the isolate is susceptible to oxacillin, cefazolin, and trimethoprim-sulfamethoxazole, but resistant to penicillin G.

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

A 12-year-old girl is brought to the pediatrician by her mother for a routine well-child visit. The mother expresses concern that her daughter has not yet experienced her first menstrual period, noting that several of the patient's classmates have already reached menarche. The patient's medical history is unremarkable, and she takes no medications. Her height is at the 75th percentile and weight is at the 60th percentile for age. A review of her growth chart indicates she experienced a significant acceleration in her linear growth rate approximately 6 months ago. On physical examination, breast tissue and areolae are enlarged and form a single continuous contour. Genital examination reveals dark, coarse, curly pubic hair that is confined to the mons pubis. The parents ask what physical changes they should expect next before menarche begins. Which of the following physical examination findings is most likely to immediately precede or coincide with the onset of this patient's menarche?

A 58-year-old man is brought to the emergency department by his family due to fever, severe headache, and progressively worsening confusion that started 12 hours ago. He has a history of type 2 diabetes mellitus and hypertension. His temperature is 39.2°C (102.6°F), blood pressure is 142/86 mmHg, pulse is 112/min, and respirations are 18/min. Physical examination reveals marked nuchal rigidity. Neurologic examination shows a lethargic patient who only opens his eyes to painful stimuli. He demonstrates a new-onset left-sided pronator drift. Arrange the following management steps in the most appropriate chronological order for this patient.

Match each diagnostic hematologic profile with its corresponding primary molecular pathogenesis and targeted therapeutic approach.

An oncology clinic evaluates a patient undergoing induction chemotherapy for acute myeloid leukemia who developed chills and a high temperature earlier today. The patient reports generalized weakness but denies cough, dysuria, abdominal pain, or skin changes. Vital signs show a temperature of $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure of $118/76\text{ mmHg}$, heart rate of $105/\text{min}$, and respiratory rate of $16/\text{min}$. Physical examination is unremarkable, with clear lung fields and no induration or erythema at the central venous catheter site. Laboratory studies reveal a total leukocyte count of $800/\text{mm}^3$ with $10\%$ neutrophils and $5\%$ bands. After obtaining appropriate blood and urine cultures, which of the following is the most appropriate empiric pharmacotherapy?

A $42$-year-old man with a history of advanced HIV infection (CD4 count $85/\text{mm}^3$) is brought to the emergency department by his partner due to $3$ days of high fever, severe generalized headache, and progressive lethargy. His temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $115/75 \text{ mmHg}$, pulse is $110/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals a lethargic man who is oriented only to person. He has pronounced resistance to passive neck flexion. Cranial nerve examination is notable for an inability to abduct the right eye. The remainder of the examination is unremarkable. Arrange the following steps in the most appropriate sequential order for the management of this patient.

An infant boy aged 9 months is evaluated during a routine health maintenance visit. His parents are anxious about his development after comparing him to other children in their playgroup. The parents report that he can sit without support and pull himself to a standing position using the furniture, but he has not begun to take independent steps. While eating, he grasps small cereal pieces using his thumb and two fingers rather than utilizing a mature grip with just his thumb and index finger. In addition, the infant babbles frequently and says "mama" and "dada," but he uses these sounds indiscriminately without referring specifically to either parent. Over the past month, he has also started crying inconsolably whenever his parents leave him with a familiar babysitter. The physical examination shows a well-appearing, interactive infant with normal muscle tone and reflexes. Which of the following is the most appropriate next step in management?

Paramedics bring a 35-year-old previously healthy male to the emergency department after he was found lethargic at home. His wife reports he has been complaining of an excruciating diffuse headache and photophobia since yesterday. Vital signs show a temperature of 39.2°C (102.6°F), pulse of 118/min, and blood pressure of 105/65 mmHg. Neurologic examination demonstrates a depressed level of consciousness and clear bilateral papilledema. The care team suspects acute bacterial meningitis and prepares to manage the patient. Arrange the following interventions in the correct procedural sequence.

During a routine health maintenance visit, the mother of a 6-month-old male infant expresses anxiety regarding his motor skills. She notes that her older daughter was already sitting upright completely unassisted by this age, but the patient immediately falls over if not propped up with pillows. Current developmental history reveals that he successfully rolls over in both directions, grasps toys with a raking motion, turns his head toward familiar voices, and babbles. Physical examination shows no abnormalities, and muscle tone is symmetric. Which of the following is the most appropriate action for the physician to take?

During a pediatric developmental assessment workshop, a medical student is asked to review the expected acquisition of various motor and adaptive skills. To demonstrate an understanding of normal growth and development across different domains, arrange the following pediatric milestones in the correct chronological order of their anticipated emergence in a typically developing child, from earliest to latest.

A general internist is conducting preoperative evaluations for several patients scheduled for elective surgeries next week. Match each patient's chronic medication scenario to the most appropriate perioperative management recommendation.

A medical student is reviewing the electronic medical record of a healthy 5-year-old boy. The record contains several physician observations made during routine well-child visits over the years. Assuming the child achieved all developmental milestones at the typical expected age without delay, arrange the following documented observations in chronological order from earliest to latest appearance.

Emergency medical services bring a 68-year-old male to the resuscitation bay due to progressive unresponsiveness and profound weakness over the last two days. According to his family, he recently recovered from a mild viral upper respiratory infection. His past medical history is significant for severe chronic obstructive pulmonary disease, ischemic cardiomyopathy with an ejection fraction of 35%, and a nonfunctioning pituitary macroadenoma for which he underwent transsphenoidal surgical resection six months ago. He was prescribed multiple replacement therapies postoperatively but abruptly discontinued all medications three weeks ago due to loss of insurance.

Vital signs show a temperature of 35.4 °C (95.7 °F), pulse of 46/min, blood pressure of 74/40 mm Hg, respirations of 24/min, and oxygen saturation of 89% on room air. Physical examination reveals a somnolent, difficult-to-arouse patient. Jugular venous distension is absent. Chest auscultation demonstrates distant breath sounds with prolonged expiration and faint diffuse wheezing, but no crackles. Cardiac examination shows a regular, bradycardic rhythm with muffled heart sounds. The extremities are cool with delayed capillary refill, and there is notable non-pitting periorbital and lower extremity edema.

Electrocardiogram demonstrates sinus bradycardia with low-voltage QRS complexes.

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

A 56-year-old woman is evaluated in the hospital on the third day of her admission for acute complicated pyelonephritis. On presentation to the emergency department, she had severe right flank pain, a temperature of 39.2°C (102.6°F), and a blood pressure of 90/60 mm Hg. After initial intravenous fluid resuscitation, her hemodynamics normalized, and she was admitted to the medical ward. She was empirically started on intravenous cefepime and vancomycin. Today, the patient reports that her flank pain has nearly resolved. She has been afebrile for the past 24 hours and is tolerating a regular diet without nausea or vomiting. Her current blood pressure is 122/78 mm Hg and pulse is 76/min. Blood and urine cultures obtained on admission both grow Escherichia coli. Susceptibility testing indicates the isolate is resistant to ampicillin but susceptible to ceftriaxone, piperacillin-tazobactam, ciprofloxacin, and trimethoprim-sulfamethoxazole. Which of the following is the most appropriate next step in the management of this patient's infection?

Match each clinical presentation to its most likely cause of secondary hypertension.

A 42-year-old man is brought to the emergency department due to progressive fatigue, easy bruising, and bleeding gums for the past week. His temperature is 37.8°C (100.0°F), blood pressure is 110/70 mm Hg, and pulse is 98/min. Physical examination shows diffuse petechiae over the extremities and oozing from the gingiva.

Laboratory studies show:

A peripheral blood smear reveals numerous atypical promyelocytes with folded nuclei and multiple needle-like intracytoplasmic inclusions (Auer rods).

Arrange the following management steps in the most appropriate chronological order.

Match each clinical vignette describing an adverse pharmacologic event to the most accurate underlying pharmacokinetic or pharmacodynamic mechanism of drug interaction.

During well-child visits, developmental surveillance is critical for early identification of delays. Various gross motor, fine motor, and adaptive milestones predictably emerge at specific ages. Match each set of developmental milestones to the most appropriate chronological age of the child.

A 42-year-old woman is brought to the emergency department due to severe agitation, palpitations, and confusion. Her family reports she has a history of Graves disease but stopped taking her prescribed medications three months ago. On presentation, her temperature is 39.4°C (102.9°F), blood pressure is 160/70 mm Hg, and pulse is 145/min and irregular. Physical examination reveals a diffuse, nontender goiter, bilateral proptosis, a fine resting tremor, and a hyperdynamic precordium. ECG demonstrates atrial fibrillation with a rapid ventricular response. She is diagnosed with thyroid storm based on clinical criteria.

Arrange the following management steps in the correct chronological sequence for this patient, from the initial acute intervention to definitive long-term therapy.

A 52-year-old man was admitted to the hospital 3 days ago for acute pyelonephritis. At the time of admission, he presented with a temperature of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), left-sided costovertebral angle tenderness, and leukocytosis. He was empirically started on intravenous piperacillin-tazobactam. Currently, he has been afebrile for 24 hours, his flank pain has largely resolved, and he is eating a regular diet without nausea. The urine culture obtained on admission has grown $>100,000\text{ CFU/mL}$ of *Escherichia coli*. Antimicrobial susceptibility testing indicates the isolate is susceptible to trimethoprim-sulfamethoxazole, levofloxacin, ceftriaxone, and piperacillin-tazobactam. Which of the following is the most appropriate next step in the management of this patient's infection?