All practice questions

Evaluated in the emergency department for severe nausea, vomiting, and vaginal bleeding, a 22-year-old primigravida reports her last menstrual period occurred $10$ weeks ago. Her blood pressure is $155/95$ mm Hg, and her pulse is $110$/min. Physical examination reveals a uterus that is palpable midway between the pubic symphysis and the umbilicus. Fetal heart tones cannot be auscultated by Doppler. Quantitative serum $\beta$-hCG is $250,000$ mIU/mL. Pelvic ultrasonography demonstrates a heterogeneous, echogenic intrauterine mass containing multiple small cystic spaces, with no fetal pole identified. Which of the following is the most appropriate next step in the management of this patient?

A 2-week-old full-term female infant is brought to the emergency department due to a 12-hour history of persistent bilious vomiting. The parents report that she has become increasingly lethargic and has not had a wet diaper in the past 18 hours. On physical examination, her temperature is 37.6°C (99.7°F), heart rate is 185/min, respiratory rate is 55/min, and blood pressure is 55/35 mm Hg. The abdomen is notably distended and rigid to palpation with involuntary guarding. Bowel sounds are absent. Capillary refill is delayed at 4 seconds. An upright abdominal X-ray reveals a paucity of distal bowel gas. Following initial fluid resuscitation, what is the most appropriate next step in management?

A 72-year-old man is brought to the emergency department by ambulance after losing consciousness at home. His wife reports that he had a brief episode of vomiting bright red blood earlier in the morning, which stopped spontaneously. However, just before the ambulance arrived, he experienced a massive episode of hematemesis and collapsed. His medical history is significant for hypertension, hyperlipidemia, tobacco use, and an open infrarenal abdominal aortic aneurysm repair four years ago. On arrival, he is diaphoretic and pale. His temperature is 37.1°C (98.8°F), blood pressure is 75/40 mmHg, pulse is 132/min, and respirations are 22/min. The abdomen is soft, non-tender, and mildly distended. Peripheral pulses are weak but symmetric. Two large-bore intravenous lines are placed and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A $24$-year-old woman, gravida $1$, para $0$, presents to the clinic for a scheduled prenatal visit at $16$ weeks gestation. She reports feeling well and has recently begun to notice fetal movement. Her pre-pregnancy body mass index was $21 \text{ kg/m}^2$. Vital signs include a blood pressure of $106/66 \text{ mm Hg}$ and a heart rate of $82/\text{min}$. Physical examination reveals a fundal height palpable midway between the pubic symphysis and the umbilicus. Routine laboratory testing yields the following results:

Blood urea nitrogen: $6 \text{ mg/dL}$
Serum creatinine: $0.5 \text{ mg/dL}$
Hemoglobin: $11.2 \text{ g/dL}$
Urinalysis: $1+$ glucose, negative for protein, negative for nitrites

Which of the following physiologic adaptations best explains this patient's laboratory findings?

A pediatric hematology and oncology team is reviewing diagnostic studies for several newly admitted children. Match each characteristic cytogenetic or molecular finding with its corresponding pediatric malignancy.

A 19-year-old college sophomore is evaluated at the university counseling center for a 6-month history of severe anxiety. She reports experiencing frequent, distressing images of herself being covered in deadly bacteria. To relieve this distress, she spends up to 4 hours a day washing her hands and disinfecting her belongings, causing her to fail two classes this semester. Three weeks ago, she visited a community clinic for low mood and was prescribed phenelzine, which she has been taking daily. She is now seeking treatment specifically for her intrusive thoughts and repetitive behaviors. Which of the following are appropriate management steps? (Select 2)

Match each clinical presentation occurring during the puerperium with its most likely underlying diagnosis.

Review the clinical scenarios detailing specific presentations and histopathologic findings of various gynecologic neoplasms. Match each patient vignette with the most appropriate primary serum tumor marker used for disease surveillance.

A 28-year-old woman presents to the clinic reporting an absence of menses for the past six months. Her menstrual cycles were previously regular, occurring every 28 days and lasting 5 days. Her body mass index is 23 kg/m². She has no significant past medical history, takes no medications, and uses condoms for contraception. Vital signs are within normal limits. Physical examination reveals normal breast development and female hair distribution. There is no galactorrhea, hirsutism, or thyromegaly. Place the following diagnostic steps in the most appropriate chronological sequence for the initial evaluation of this patient's secondary amenorrhea.

A $3$-year-old girl is brought to the emergency department by her parents, who state they have declined all childhood vaccinations due to personal beliefs. She developed a sudden-onset high fever and severe sore throat $4$ hours ago. The patient is currently sitting upright on her father's lap, leaning forward with her chin thrust outward. She is drooling profusely and her voice sounds thick and muffled when she attempts to speak. Vital signs show a temperature of $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), heart rate of $155 \text{ /min}$, and respiratory rate of $48 \text{ /min}$. Marked inspiratory stridor is audible without a stethoscope.

Arrange the following management steps in the most appropriate sequential order for this patient, from first step to final step.

A 34-year-old nulliparous woman is evaluated in the clinic after a routine Papanicolaou (Pap) smear demonstrates a high-grade squamous intraepithelial lesion (HSIL). She has no significant past medical history, and her previous Pap smears were normal. She wishes to preserve her fertility. Arrange the following clinical steps in the most appropriate chronological sequence for the diagnosis, definitive management, and surveillance of this patient according to standard clinical guidelines.

Match the following physiological mechanisms of normal pregnancy with their expected clinical or laboratory manifestations.

A $63$-year-old G2P2 woman presents to the clinic reporting vaginal dryness, dyspareunia, and two episodes of light vaginal spotting over the last month. She attained menopause at age $51$. Medical history is significant for hypertension and osteoarthritis. Vital signs are within normal limits. Pelvic examination reveals thin, pale, and friable vaginal mucosa with diminished rugae. No cervical or vulvar lesions are visualized. Bimanual examination reveals a small, mobile uterus and no adnexal masses. A transvaginal ultrasound performed in the office shows a homogeneous endometrial stripe with a thickness of $7\text{ mm}$ and normal bilateral ovaries. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical vignette describing a distinct peripheral vascular presentation to its most appropriate anatomic diagnosis or pathophysiologic syndrome.

Match each patient's preoperative medication profile with the most appropriate perioperative management strategy for that specific medication.

A 45-year-old man comes to the emergency department due to intermittent, crampy abdominal pain and nausea for the past 24 hours. He has vomited twice and has not passed flatus since yesterday. His surgical history is significant for an open appendectomy for a perforated appendix 10 years ago.

Vital signs include a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse of $88/\text{min}$, respirations of $14/\text{min}$, and blood pressure of $130/82\text{ mm Hg}$. The abdomen is moderately distended and tympanitic to percussion. High-pitched, hyperactive bowel sounds are auscultated. There is mild, diffuse abdominal tenderness to deep palpation, but no guarding, rigidity, or rebound tenderness is present.

Laboratory studies show a leukocyte count of $8,200/\text{mm}^3$ and a normal basic metabolic panel. A CT scan of the abdomen and pelvis with intravenous contrast reveals dilated loops of small bowel up to $4\text{ cm}$ in diameter, a transition point in the distal ileum, and a collapsed colon. The bowel wall enhances normally, and there is no evidence of pneumatosis intestinalis, free intraperitoneal air, or free fluid.

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

A series of patients present to the trauma bay with various acute orthopedic injuries. Match each specific fracture pattern or dislocation with its most likely associated neurovascular deficit observed on physical examination.

A $19$-year-old male college student is brought to the emergency department $30$ minutes after a bicycle accident. He was riding down a steep trail when he lost control, flipped over the handlebars, and struck his left upper abdomen against a large rock. He complains of severe abdominal pain and pain radiating to his left shoulder. His temperature is $36.8^{\circ}\text{C}$ ($98.2^{\circ}\text{F}$), blood pressure is $82/50$ mm Hg, pulse is $130$/min, and respirations are $24$/min. Pulse oximetry shows $98\%$ on room air. He appears pale and diaphoretic. Physical examination reveals ecchymosis over the left upper quadrant. The abdomen is distended, rigid, and diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) exam demonstrates a large anechoic stripe in the splenorenal recess and hepatorenal recess. Two large-bore intravenous lines are established, and fluid resuscitation with $1$ L of warmed crystalloid is initiated. Repeat blood pressure is $84/52$ mm Hg. Which of the following is the most appropriate next step in management?

A $68$-year-old male is evaluated in the intensive care unit on postoperative day $2$ following an emergent open repair of a ruptured abdominal aortic aneurysm. During the procedure, he received $8\text{ L}$ of crystalloid and $6$ units of packed red blood cells. The patient remains intubated and mechanically ventilated. Over the past $4$ hours, his urine output has dropped to $5\text{ mL/hr}$. Current vital signs include a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure of $82/50\text{ mmHg}$, and heart rate of $124/\text{min}$. The ventilator is alarming for high peak airway pressures, which have increased from $24\text{ cm H}_2\text{O}$ to $48\text{ cm H}_2\text{O}$ since the morning. Central venous pressure is $19\text{ mmHg}$. Physical examination reveals a tightly distended, firm abdomen and bilateral basilar crackles. Laboratory studies demonstrate a serum creatinine of $2.7\text{ mg/dL}$ (baseline $1.0\text{ mg/dL}$) and a leukocyte count of $15,500/\mu\text{L}$. Which of the following is the most appropriate next step in management?

Match each upper extremity fracture or dislocation pattern with its most classically associated neurovascular complication.