All practice questions

Review the clinical vignettes describing five different patients presenting with hematologic abnormalities. Based on the provided clinical presentations and laboratory profiles, which peripheral blood smear finding best matches each patient?

A 68-year-old man is brought to the emergency department by his daughter due to worsening confusion, profound fatigue, and severe lower back pain over the past two weeks. He has a history of hypertension. Temperature is 37.1°C (98.8°F), blood pressure is 110/70 mmHg, pulse is 112/min, and respiratory rate is 16/min. Physical examination reveals dry mucous membranes and point tenderness over the L3 and L4 vertebrae. Neurologic examination shows no focal deficits, but the patient is lethargic and oriented only to name.

Laboratory studies show:
- Hemoglobin: 8.9 g/dL
- Platelet count: 140,000/mm³
- Leukocyte count: 4,500/mm³
- Serum calcium: 13.8 mg/dL
- Serum creatinine: 2.8 mg/dL (baseline 0.9 mg/dL)
- Blood urea nitrogen: 56 mg/dL
- Total protein: 10.2 g/dL
- Albumin: 3.1 g/dL

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

A $55$-year-old woman with a history of diffuse large B-cell lymphoma presents to the emergency department with chills and a fever. She received her last cycle of R-CHOP chemotherapy $8$ days ago. Her temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, and heart rate is $105/\text{min}$. Physical examination reveals a central venous port in the right upper chest with no surrounding erythema. Her absolute neutrophil count is pending but is suspected to be severely low.

Arrange the following steps in the correct chronological order for the optimal initial and subsequent management of this patient's condition.

A 9-month-old female infant is brought to the clinic by her parents for a routine well-child evaluation. She was born at 28 weeks of gestation via spontaneous vaginal delivery following preterm labor. Her neonatal intensive care unit stay was prolonged, but she was eventually discharged home in stable condition without oxygen dependence. The parents are highly concerned that she is falling behind her peers in their neighborhood playgroup. They report she cannot crawl, pull herself to a standing position, or pick up small snacks with her thumb and index finger. She has no other significant past medical history. On physical examination, the infant appears well-nourished and interactive. She is able to sit unsupported momentarily but primarily relies on placing her hands in front of her for balance when leaning forward. She successfully transfers a small toy from one hand to the other. When offered a small piece of cereal, she uses a raking motion with all her fingers to grasp it. She babbles single syllables but does not use words meaningfully. When the physician holds the infant in vertical suspension and abruptly lowers her headfirst toward the examination table, she does not extend her arms to break the fall. Which of the following is the most accurate assessment of this patient's developmental status?

Targeted biologic and synthetic disease-modifying antirheumatic drugs (DMARDs) have revolutionized the management of rheumatologic conditions, but they carry risks for unique and severe adverse effects. Match each clinical vignette describing a therapy-related complication with the specific medication class most likely responsible.

A 38-year-old woman is brought to the emergency department by her husband due to a 2-day history of progressive, ascending muscle weakness and difficulty breathing. She also reports palpitations. She has a 5-year history of severe dry eyes, a persistent sensation of "cotton mouth," and recurrent bilateral parotid gland swelling. Her only daily medication is artificial tears.

Physical examination reveals a respiratory rate of 28/min, heart rate of 115/min, and blood pressure of 110/70 mmHg. She is using accessory muscles of respiration. Neurologic examination shows 2/5 motor strength in her proximal lower and upper extremities, and globally diminished deep tendon reflexes.

Laboratory studies show:
Sodium: 140 mEq/L
Potassium: 1.8 mEq/L
Chloride: 118 mEq/L
Bicarbonate: 10 mEq/L

Arterial blood gas on room air:
pH: 7.22
$PaCO_2$: 38 mmHg
$PaO_2$: 85 mmHg

Endocrine studies obtained due to her profound weakness show a TSH of 0.2 $\mu U/mL$ (Normal: 0.4-4.0) and Free T4 of 0.6 ng/dL (Normal: 0.8-1.8).

Urinalysis shows a pH of 6.5 and 15 WBC/hpf. A urine culture obtained at an urgent care clinic two days ago is now resulting, showing >100,000 CFU/mL of *Escherichia coli* that is sensitive to nitrofurantoin, cephalexin, and trimethoprim-sulfamethoxazole.

Which of the following is the most accurate interpretation of this patient's current condition and the most appropriate initial management step?

For each pediatric patient presented below, select the most appropriate routine preventive care intervention or immunization milestone recommended for their specific age according to standard pediatric guidelines.

Review the following clinical vignettes describing patients who are experiencing complications related to underlying malignancies. Match each patient's clinical presentation with the primary pathophysiologic mechanism responsible for their symptoms.

During a routine wellness check, a 68-year-old retired carpenter describes gradually worsening right knee discomfort over the past two years. He notes the pain is most pronounced after an afternoon of gardening and improves when he sits in his recliner. He denies any systemic symptoms such as fever, fatigue, or unintended weight loss. Morning joint stiffness is minimal, rarely exceeding 15 minutes. Physical assessment of the right knee demonstrates palpable crepitus during active range of motion and prominent bony hypertrophy, but lacks joint effusion, significant warmth, or overlying erythema. A recent complete blood count and inflammatory marker panel were within normal limits. Which of the following pathophysiologic processes best explains this patient's current clinical presentation?

A 52-year-old man is evaluated in the clinic for resistant hypertension. Despite adherence to a regimen of amlodipine, lisinopril, and chlorthalidone at maximum tolerated doses, his blood pressure remains poorly controlled at 168/102 mm Hg. He reports occasional muscle weakness but is otherwise asymptomatic. Laboratory studies reveal a serum potassium level of 3.1 mEq/L and a serum sodium level of 144 mEq/L. The physician suspects a secondary cause for his resistant hypertension. Arrange the following diagnostic steps in the most appropriate chronological order to definitively evaluate and subtype this patient's condition.

A 74-year-old male patient with known metastatic prostate carcinoma is evaluated in the emergency department for severe mid-thoracic back pain that has been escalating over the past week. During the last 24 hours, he has noted profound weakness in both of his legs and an inability to void urine. Vital signs are within normal limits. Neurologic evaluation demonstrates a motor strength of $2/5$ in bilateral lower extremities, hyperactive patellar reflexes, positive Babinski signs bilaterally, and diminished pain sensation below the umbilicus.

Arrange the following steps in the most appropriate chronological order for the optimal management of this patient.

During a routine primary care visit, the parents of a 5-year-old girl inquire about updating her vaccination status. The patient has a history of acute lymphoblastic leukemia, which was diagnosed six months ago, and she is actively receiving maintenance chemotherapy. Today, she appears well, and her temperature is 36.8°C (98.2°F). Her vaccination records indicate that she is due for her standard 4-to-6-year booster series, consisting of the diphtheria, tetanus, and acellular pertussis (DTaP); inactivated poliovirus (IPV); measles, mumps, and rubella (MMR); and varicella vaccines. What is the most appropriate approach to this patient's immunizations at this time?

A couple brings their 15-month-old daughter to the primary care clinic for a scheduled well-child visit. They are anxious because their friends' children of the same age are already walking independently, whereas their daughter only walks while holding onto furniture. The girl was born full-term and her medical history is unremarkable. On observation in the clinic, she easily pulls herself to a standing position and cruises smoothly along the examination table. When sitting, she uses a mature pincer grasp to pick up a small piece of cereal and successfully places a block into a cup. She babbles with varied inflection, uses the words "mama," "dada," and "ball" correctly, and follows a simple one-step command without needing an accompanying gesture. She maintains good eye contact and frequently points to objects she desires. Physical examination reveals normal muscle bulk and tone, and deep tendon reflexes are 2+ and symmetric in all extremities. Which of the following is the most appropriate next step in management?

A 24-year-old woman, gravida 2 para 1, at 18 weeks gestation, presents to the clinic with a diffuse maculopapular rash that includes her palms and soles. She also reports generalized malaise and a low-grade fever over the past week. Her medical history is notable for a severe anaphylactic reaction (hypotension, wheezing, and angioedema) to amoxicillin prescribed for a respiratory infection two years ago. Laboratory evaluation reveals a rapid plasma reagin (RPR) titer of 1:64 and a reactive fluorescent treponemal antibody absorption (FTA-ABS) test. Arrange the following management steps in the most appropriate chronological order for this patient.

A 45-year-old female patient presents to a primary care office complaining of unexpected weight gain, weakness in her thighs, and frequent bruising over the past six months. On examination, she has a plethoric face, prominent supraclavicular fat pads, and violaceous striae across her abdomen. Vital signs show a blood pressure of 155/95 mm Hg. Arrange the following diagnostic steps in the most appropriate chronological order to properly evaluate this presentation.

During a routine clinic visit, a 62-year-old male veteran complains of severe, widespread itching that reliably occurs within minutes of stepping out of a warm shower. He also reports recent onset of headaches and a sensation of fullness in his head. Physical examination reveals a ruddy facial complexion and a palpable spleen edge extending $3$ cm below the left costal margin. Laboratory studies reveal:

Which of the following is the most appropriate next diagnostic step for this patient?

A 22-year-old man is admitted to the hospital for initiation of induction chemotherapy for recently diagnosed Burkitt lymphoma. His medical history is significant for an episode of acute jaundice, fatigue, and dark urine two years ago after taking primaquine for malaria prophylaxis; the episode spontaneously resolved upon discontinuation of the medication. The patient currently feels well and reports no symptoms. His temperature is 37.1°C (98.8°F), blood pressure is 120/78 mm Hg, and pulse is 82/min. Physical examination reveals prominent cervical and axillary lymphadenopathy but is otherwise unremarkable.

The patient is started on aggressive intravenous normal saline hydration. Which of the following is the most appropriate next step in the management of this patient's hyperuricemia?

Match each specific autoantibody profile with its most strongly associated rheumatologic condition.

A 34-year-old woman is brought to the emergency department by her husband due to progressive confusion and severe fatigue over the past 48 hours. She also complains of a new-onset rash on her lower extremities. She has no significant past medical history and takes no medications. Temperature is 38.1°C (100.6°F), blood pressure is 142/85 mm Hg, pulse is 110/min, and respiratory rate is 18/min. Physical examination reveals mild scleral icterus and pale conjunctivae. There are numerous pinpoint, non-blanching red macules over both lower extremities. Neurological examination is notable for mild disorientation to time and place, but no focal motor or sensory deficits are present.

Laboratory results are as follows:

A peripheral blood smear demonstrates numerous fragmented red blood cells.

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

A physician is evaluating the antimicrobial regimen of a patient on the medical floor. The patient, a 58-year-old male, was admitted three days prior for management of severe shortness of breath and a productive cough. At the time of admission, imaging confirmed a left lower lobe consolidation, prompting the initiation of empiric intravenous ceftriaxone and azithromycin. Currently, the patient is clinically stable, breathing comfortably on ambient air, and tolerating his regular diet. He has not had a fever for over 24 hours. Laboratory data today reveals that the initial blood cultures are sterile. However, the admission sputum culture has finalized, demonstrating heavy growth of *Streptococcus pneumoniae*. Susceptibility profiling indicates the isolate is sensitive to penicillin, amoxicillin, levofloxacin, ceftriaxone, and vancomycin. Which of the following is the most appropriate next step in the pharmacologic management of this patient?