All practice questions

A 45-year-old man is hospitalized for the treatment of acute promyelocytic leukemia. Eight days ago, he was started on induction therapy with all-trans retinoic acid and arsenic trioxide, along with empiric intravenous cefepime for neutropenic fever. Over the last $24$ hours, his temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, pulse is $112/\text{min}$, and respirations are $24/\text{min}$. Oxygen saturation is $89\%$ on room air. He reports progressive shortness of breath and a nonproductive cough. Physical examination reveals bilateral basilar crackles, $2+$ bilateral lower extremity edema, and elevated jugular venous pressure. Laboratory studies show a leukocyte count of $28,000/\text{mm}^3$ (up from $4,000/\text{mm}^3$ on admission). Chest radiography demonstrates bilateral diffuse interstitial opacities and small bilateral pleural effusions. Which of the following is the most specific and critical next step in the management of this patient's acute respiratory decompensation?

Match each patient's clinical presentation and laboratory profile with the most likely corresponding peripheral blood smear finding.

A 52-year-old woman with a history of primary Sjögren syndrome, characterized by severe keratoconjunctivitis sicca, xerostomia, and positive anti-Ro/SSA antibodies, is brought to the emergency department by her husband due to sudden, profound generalized muscle weakness that started this morning. She reports feeling so weak she could not get out of bed. She also complains of new-onset shortness of breath and difficulty taking a deep breath. She currently takes no medications.

Temperature is 37.1°C (98.8°F), blood pressure is 115/75 mm Hg, pulse is 95/min, and respiratory rate is 24/min with shallow breathing. Pulse oximetry is 94% on room air.

Physical examination reveals 2/5 motor strength in the proximal muscles of the upper and lower extremities. Deep tendon reflexes are 1+ bilaterally. Chest auscultation reveals clear lungs bilaterally.

Laboratory studies show:

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

A 24-year-old woman is seen in the ambulatory care center for evaluation of easy bruising and frequent nosebleeds. She reports that her epistaxis occurs spontaneously and often requires up to 20 minutes of direct compression to resolve. Furthermore, she has experienced exceptionally heavy menstrual bleeding since menarche, frequently bleeding through super-absorbent tampons every 2 hours during the heaviest days of her cycle. Last month, a dental extraction was complicated by continuous mucosal oozing that persisted for 48 hours. She has no other medical conditions and does not take any prescription or over-the-counter medications. Her vital signs are within normal limits. Physical examination reveals several small ecchymoses on her bilateral lower extremities, but no petechiae, hemarthroses, or hepatosplenomegaly are noted. The physician suspects an underlying inherited bleeding diathesis.

Arrange the following steps in the diagnostic and management algorithm for this patient in the correct chronological sequence, from initial screening to therapeutic planning.

A 42-year-old woman is newly diagnosed with seropositive rheumatoid arthritis. She presents with symmetric polyarthritis involving the metacarpophalangeal and proximal interphalangeal joints, morning stiffness lasting 3 hours, and early marginal erosions on hand radiography. Assuming she experiences an initial inadequate clinical response to each successive pharmacological intervention, but eventually achieves and maintains deep remission, arrange the following management steps in the standard evidence-based sequence according to current treatment guidelines.

Match each patient's clinical presentation with the most appropriate specific therapeutic intervention.

A 41-year-old woman recently diagnosed with limited cutaneous systemic sclerosis seeks care for progressively worsening color changes and throbbing pain in her fingers upon cold exposure. Over several years, her symptoms progressively escalate despite compliance with each prescribed treatment regimen, eventually leading to severe digital ischemia and impending gangrene. Arrange the following therapies for secondary Raynaud phenomenon in the standard stepwise order of clinical escalation, from initial baseline management to interventions for medically refractory, limb-threatening disease.

For each patient presentation describing a new diagnosis of primary hypertension with specific comorbidities, select the most appropriate preferred initial antihypertensive medication class.

During a scheduled wellness examination, a 72-year-old male mentions to his physician that his daily neighborhood walks have become increasingly difficult over the last three months due to profound fatigue. He has no prior history of cardiopulmonary disease and denies melena, hematochezia, changes in bowel habits, or abdominal pain. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure 135/82 mm Hg, pulse 86/min, and respirations 14/min. Physical examination demonstrates noticeable conjunctival pallor. The abdomen is soft and non-tender without hepatosplenomegaly.

Laboratory evaluation reveals the following:

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

A $68$-year-old man is admitted to the general medical floor with a $4$-day history of fever, chills, and a cough productive of rust-colored sputum. His past medical history is significant only for benign prostatic hyperplasia. He has not had any recent hospitalizations, does not reside in a nursing facility, and has not received any antibiotics in the past year. Vital signs on presentation include a temperature of $38.8^{\circ}\text{C}$ ($101.8^{\circ}\text{F}$), blood pressure of $115/76\text{ mm Hg}$, pulse of $102/\text{min}$, and respiratory rate of $24/\text{min}$. Oxygen saturation is $94\%$ on $2\text{ L/min}$ via nasal cannula. Chest radiography demonstrates a dense consolidation in the left lower lobe. The admitting physician empirically prescribes intravenous piperacillin-tazobactam and vancomycin. A high-quality sputum Gram stain demonstrates many polymorphonuclear leukocytes and abundant Gram-positive diplococci. Which of the following is the most appropriate modification to this patient's antimicrobial regimen?

An athletic 24-year-old male construction worker presents with an 8-month history of insidious-onset lower back pain and severe morning stiffness. He reports that the stiffness often lasts for over an hour after awakening but gradually improves as he engages in physical labor throughout the day. His symptoms frequently awaken him in the second half of the night. He denies any radiating leg pain, numbness, or bowel/bladder dysfunction. Physical examination reveals a restricted range of motion in the lumbar spine, as evidenced by a modified Schober test expansion of only $3\text{ cm}$ (normal $>5\text{ cm}$). Neurologic examination of the lower extremities is unremarkable.

Assuming the patient's initial imaging studies do not yield a definitive diagnosis and his symptoms remain unacceptably high despite initial interventions, arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for establishing the diagnosis and managing this patient according to standard rheumatologic guidelines.

Match the following key socioemotional and play milestones to the most typical chronological age at which they first emerge during normal pediatric development.

A 27-year-old woman is brought to the emergency department due to a 2-day history of progressively worsening shortness of breath, fever, and coughing up blood-tinged sputum. She has a history of systemic lupus erythematosus (SLE) complicated by class IV lupus nephritis, for which she takes mycophenolate mofetil and low-dose prednisone. Her temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, pulse is $124/\text{min}$, and respirations are $28/\text{min}$. Oxygen saturation is $86\%$ on room air. Physical examination reveals a pale, fatigued woman in moderate respiratory distress. Auscultation of the lungs reveals diffuse bilateral crackles. There is no jugular venous distension. Cardiac examination shows a regular tachycardia with no murmurs, rubs, or gallops. Trace bilateral pedal edema is present.

Chest radiograph reveals new diffuse, bilateral patchy alveolar infiltrates. An emergency bedside echocardiogram demonstrates a left ventricular ejection fraction of $60\%$ with normal right ventricular function and no significant valvular abnormalities.

Which of the following diagnostic findings would most likely be seen on further evaluation of this patient?

Match each patient's clinical presentation with the most appropriate initial pharmacological intervention.

A 30-month-old boy is brought to the office by his parents for a routine well-child visit. His parents express concern regarding his development. They note that he does not play cooperatively with other children at the local park, preferring to play independently next to them, and he frequently refuses to share his toys. Additionally, they are worried because he cannot yet pedal a tricycle or draw a circle. On physical examination, the child is active and cooperative. He walks up the examination step stool by placing both feet on each step and successfully jumps in place. He builds a tower of eight blocks and holds a crayon to make vertical lines. He speaks in two- to three-word phrases, has a vocabulary of approximately 100 words, and refers to himself as "I." His speech is understood by the physician roughly half the time. Which of the following is the most appropriate next step in management?

Parents bring their 2-year-old son to the pediatric clinic because they are highly concerned about his frequent, severe temper tantrums. When he is denied a toy, he frequently throws himself on the floor, kicks, and screams. During the most severe episodes, he cries vigorously, stops breathing, and turns slightly blue around the lips before taking a deep breath and recovering spontaneously. He has never lost consciousness.

On developmental assessment, the boy walks well, runs, kicks a ball, and can build a tower of 6 cubes. He points to objects he wants and brings books to his parents to read. His vocabulary consists of "mama," "dada," "dog," and "no." He does not put two words together. He makes good eye contact, smiles reciprocally, and plays alongside his older sister in the waiting room.

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

A 5-year-old boy is brought to the clinic for a well-child examination prior to starting kindergarten. His medical history is notable for severe polyarticular juvenile idiopathic arthritis. For the past 6 months, his condition has been exceptionally well controlled on a regimen of subcutaneous etanercept and oral methotrexate. His mother states he has been entirely asymptomatic. A review of his immunization records shows that he received all required infant and toddler vaccinations up to age 2, but he has not yet received any of his standard preschool booster vaccines. The mother also expresses concern that her son cannot yet copy a diamond or independently tie his shoelaces. Observation in the clinic reveals he can skip, copy a triangle, and accurately count to 10. Vital signs and physical examination are normal. Which of the following is the most appropriate management plan for this patient today?

A 54-year-old man is brought to the emergency department by his partner due to a 24-hour history of severe headache, high fever, and worsening confusion. He has a history of advanced HIV infection and has been non-adherent to his antiretroviral therapy. His temperature is 39.4°C (102.9°F), blood pressure is 105/65 mmHg, and heart rate is 118/min. He is lethargic and oriented only to person. Physical examination is notable for marked resistance to passive neck flexion. Fundoscopic evaluation reveals blurring of the optic disc margins bilaterally. Arrange the following diagnostic and therapeutic interventions in the most appropriate chronological order for the immediate management of this patient.

For each of the following classic clinical presentations of infectious diseases, select the most appropriate first-line targeted antimicrobial therapy.

Match each clinical presentation of infective endocarditis or severe bacteremia to its most appropriate targeted antimicrobial regimen.