All practice questions

A 4-year-old boy is brought to the pediatric clinic by his father for a routine well-child visit. His father reports that the boy is active, eats a balanced diet, and attends preschool without issues. The boy's 7-year-old sister was recently diagnosed with acute lymphoblastic leukemia and is currently undergoing induction chemotherapy. The father expresses concern that the vaccines scheduled for the 4-year-old today might pose an infection risk to the immunocompromised sister. The boy is up to date on all prior immunizations. Vital signs are within normal limits. Physical examination reveals an energetic, well-nourished child with no abnormalities. Which of the following is the most appropriate next step in management regarding this patient's immunizations today?

A 24-year-old woman presents to the clinic with a 6-week history of a painless, progressively enlarging mass in her right lower neck. She also reports intermittent fevers and drenching night sweats over the past month. Physical examination reveals a 3.5-cm, rubbery, mobile, non-tender lymph node in the right supraclavicular region. No other lymphadenopathy or hepatosplenomegaly is appreciated. Laboratory studies show a normal complete blood count, but the erythrocyte sedimentation rate is elevated at $65 \text{ mm/hr}$. The physician suspects a hematologic malignancy. Arrange the following steps in the most appropriate chronological sequence for the diagnostic workup, staging, and initial management of this patient's most likely condition.

During a medical student's pediatrics rotation, the attending physician emphasizes the importance of recognizing the simultaneous development of different skill domains. To evaluate the student's understanding of global milestone acquisition, match the following comprehensive clinical presentations to the exact chronological age at which a healthy child is expected to demonstrate these abilities.

Match the following complex clinical scenarios and isolated pathogens with the most appropriate, definitive targeted antimicrobial therapy.

Match each patient's clinical presentation to the most likely underlying hematologic or oncologic diagnosis.

A pediatrician is evaluating a healthy 4-year-old girl during a routine well-child visit. As the physician observes the child drawing and playing with blocks, she reflects on the progressive development of fine and visual-motor skills that culminate in these abilities. Arrange the following developmental milestones in the correct chronological order of their expected emergence in a healthy child, from earliest (youngest age) to latest (oldest age).

During a routine prenatal visit at 27 weeks gestation, a 29-year-old gravida 1, para 0 reports increasing fatigue, swelling in her lower extremities, and intermittent pain in her wrists and metacarpophalangeal joints over the past two weeks. She was diagnosed with systemic lupus erythematosus four years ago, which has been quiescent on a regimen of hydroxychloroquine. Her home blood pressure readings have trended upward to approximately 145/90 mm Hg over the last several days. Vital signs today include a temperature of 37.1 C (98.8 F), blood pressure of 152/96 mm Hg, and pulse of 84/min. Physical examination confirms 2+ pitting edema extending to the mid-calves and mild synovitis in the hands. Urinalysis demonstrates 3+ proteinuria but is negative for leukocyte esterase and nitrites. The medical team is debating whether her presentation represents a primary hypertensive disorder of pregnancy or an exacerbation of her underlying autoimmune diathesis. Which of the following laboratory findings would most strongly point toward an autoimmune exacerbation?

A 58-year-old woman with a 10-year history of severe rheumatoid arthritis presents to the clinic with worsening fatigue over the past few months. Her joint pain has also been poorly controlled recently despite her current medication regimen. Vital signs are within normal limits. Physical examination reveals swollen, tender metacarpophalangeal and proximal interphalangeal joints bilaterally.

Laboratory studies show the following:

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

A 72-year-old man is brought to the emergency department by his daughter due to progressive lethargy, severe constipation, and deep lower back pain over the past week. He has a history of chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection fraction. The patient's brother is his legally appointed healthcare proxy, but the daughter is currently present and demands immediate aggressive interventions.

Upon arrival, a triage nurse accidentally administers 1 liter of 5% Dextrose in water (D5W) instead of the ordered isotonic saline. The daughter becomes furious upon realizing this and demands the nurse be fired immediately.

Temperature is 37.1°C (98.8°F), blood pressure is 115/75 mmHg, pulse is 105/min, and respirations are 16/min. Mucous membranes are dry, and he has diminished skin turgor. Neurologic examination reveals confusion and disorientation. Chest X-ray shows hyperinflated lungs. Lung auscultation reveals mild bilateral basilar crackles, which are unchanged from his baseline exams.

Laboratory studies are as follows:

A urine culture obtained two days ago at an outpatient clinic has just resulted, growing >100,000 CFU/mL of *Escherichia coli* that is sensitive to nitrofurantoin and cephalexin, but resistant to ampicillin.

Which of the following is the most appropriate next step in the management of this patient's acute condition?

A 68-year-old man with a history of benign prostatic hyperplasia is admitted to the hospital with fever, severe left flank pain, and dysuria. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $100/60\text{ mmHg}$, and heart rate is $110\text{/min}$. Laboratory studies show a leukocyte count of $18,000\text{/mm}^3$. He is empirically started on intravenous piperacillin-tazobactam and intravenous fluids.

On hospital day 3, the patient is clinically improved and afebrile. Blood and urine cultures drawn at admission both grow *Enterobacter cloacae*.

Antimicrobial susceptibility testing of the isolate reveals the following:
- Ampicillin: Resistant
- Cefazolin: Resistant
- Ceftriaxone: Sensitive (MIC $\leq 1\text{ }\mu\text{g/mL}$)
- Cefepime: Sensitive (MIC $\leq 1\text{ }\mu\text{g/mL}$)
- Piperacillin-tazobactam: Sensitive (MIC $4\text{ }\mu\text{g/mL}$)
- Meropenem: Sensitive (MIC $\leq 0.25\text{ }\mu\text{g/mL}$)

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

A pediatric clinical educator is evaluating medical residents on specialized immunization protocols for high-risk and unique pediatric populations. Review the following patient scenarios and match each patient with their most appropriate specific immunization management step.

A male neonate is examined during morning rounds at 48 hours of life. He was born at 40 weeks of gestation to a 28-year-old primigravida. The pregnancy and spontaneous vaginal delivery were uncomplicated. The infant has been breastfeeding well and has passed meconium and urine normally. His temperature is 37.1°C (98.8°F), heart rate is 135/min, and respiratory rate is 42/min. Physical examination reveals multiple erythematous macules scattered across the trunk and proximal extremities. Several of these macules have central, 1- to 2-mm, yellowish-white papules. The palms and soles are completely clear. The remainder of the physical examination, including tone and reflexes, is unremarkable. Which of the following is the most appropriate next step in management?

A 76-year-old woman is evaluated in the hospital on day 5 of her admission due to an episode of hypotension and altered mental status. She was initially admitted for a severe COPD exacerbation and has been receiving systemic glucocorticoids, nebulized bronchodilators, and prophylactic enoxaparin. An indwelling Foley catheter was placed on admission due to urinary retention and has remained in place.

Today (Day 5), her temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $88/56\text{ mmHg}$, heart rate is $112\text{/min}$, and respiratory rate is $22\text{/min}$. Physical examination reveals a lethargic patient. The abdomen is soft and non-tender, and there is no costovertebral angle tenderness. Laboratory findings show a leukocyte count of $16,500\text{/mm}^3$. A urinalysis obtained from the Foley catheter port shows $25\text{ WBCs/hpf}$ and positive leukocyte esterase, but negative nitrites.

Blood and urine cultures are drawn. The patient receives intravenous fluid resuscitation, and empiric intravenous vancomycin and cefepime are initiated.

Two days later (Day 7), the patient is clinically improved, her mental status has returned to baseline, she is hemodynamically stable off fluids, and she is afebrile. Blood cultures show no growth at 48 hours. The urine culture grows $>10^5\text{ CFU/mL}$ of *Enterococcus faecalis*.

Antimicrobial susceptibility testing for the *E. faecalis* isolate demonstrates the following:
- Ampicillin: Susceptible
- Cefepime: Resistant
- Ciprofloxacin: Resistant
- Linezolid: Susceptible
- Vancomycin: Susceptible

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

Pediatric developmental milestones are typically achieved in a predictable chronological sequence, providing a framework for developmental surveillance. Arrange the following hallmark pediatric milestones in the correct chronological order based on their anticipated age of acquisition in a healthy child, from earliest (first) to latest (last).

An emergency department physician evaluates a 62-year-old female patient reporting severe, progressively worsening mid-back pain over the past week. The pain is particularly severe in the supine position and frequently awakens her from sleep. Today, she developed bilateral lower extremity weakness and has been unable to urinate for the past 12 hours. Her medical history includes estrogen receptor-positive breast cancer, for which she underwent lumpectomy, radiation, and hormonal therapy five years ago.

Vital signs are within normal limits. Neurologic examination demonstrates $3/5$ motor strength in both legs, decreased pain and temperature sensation below the umbilicus, and hyperreflexia at the patellar and Achilles tendons. Anal sphincter tone is diminished. Bladder ultrasound reveals a post-void residual volume of $600\text{ mL}$.

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

A female patient with a longstanding history of erosive polyarthritis and frequent episodes of podagra is brought to the emergency department by her family due to mucosal bleeding, diffuse bruising, and profound weakness. Three weeks prior, her rheumatologist discontinued her tumor necrosis factor inhibitor due to loss of efficacy and initiated a new oral disease-modifying antirheumatic drug. Her home medications also include a daily prophylactic agent to prevent her foot flares. Vital signs are within normal limits, though she appears pale and fatigued. Laboratory analysis reveals:

Pharmacologic inhibition of which of the following enzymes most directly caused this patient's hematologic abnormalities?

A 68-year-old man with a history of chronic obstructive pulmonary disease (COPD) is hospitalized for induction chemotherapy for newly diagnosed acute myeloid leukemia. On day 8 of his admission, his absolute neutrophil count is $200/\text{mm}^3$ and his hemoglobin is $6.2\text{ g/dL}$. He is afebrile and hemodynamically stable. He is prescribed a transfusion of two units of packed red blood cells.

Two hours into the transfusion, he develops acute-onset severe dyspnea, tachypnea, and a dry cough.

Vital signs are as follows:
- Temperature: $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$)
- Blood pressure: $178/92\text{ mmHg}$
- Heart rate: $112/\text{min}$
- Respiratory rate: $26/\text{min}$
- $\text{SpO}_2$: $86\%$ on room air

Physical examination reveals a frail man in moderate respiratory distress using accessory muscles of respiration. Jugular venous pressure is $12\text{ cm H}_2\text{O}$. Chest auscultation reveals diffuse, prolonged expiratory wheezing with faint bibasilar crackles.

Arterial blood gas analysis on room air shows:
- pH: $7.28$
- $\text{pCO}_2$: $56\text{ mmHg}$
- $\text{pO}_2$: $54\text{ mmHg}$
- $\text{HCO}_3^-$: $25\text{ mEq/L}$

Routine morning laboratory results (drawn prior to the transfusion) show:
- Sodium: $138\text{ mEq/L}$
- Potassium: $4.2\text{ mEq/L}$
- Chloride: $102\text{ mEq/L}$
- Bicarbonate: $24\text{ mEq/L}$
- Blood urea nitrogen: $18\text{ mg/dL}$
- Creatinine: $0.9\text{ mg/dL}$
- TSH: $0.2\text{ }\mu\text{U/mL}$ (Normal: $0.4–4.0$)
- Free T4: $0.7\text{ ng/dL}$ (Normal: $0.9–1.7$)

The transfusion is immediately halted, and the patient is placed on supplemental oxygen via a non-rebreather mask. Which of the following is the most appropriate next step in the management of this patient?

An 82-year-old woman who resides in a skilled nursing facility is brought to the clinic for a routine wellness visit. She has a history of mild vascular dementia and type 2 diabetes mellitus. The patient is at her baseline cognitive function and reports no fever, chills, dysuria, increased urinary urgency, or abdominal pain. Vital signs are temperature 37.0°C (98.6°F), blood pressure 138/82 mmHg, and pulse 78/min. The abdomen is non-tender and there is no costovertebral angle tenderness. As part of a general protocol by the nursing facility, a urinalysis and urine culture were obtained prior to the visit. The urinalysis shows moderate leukocyte esterase and positive nitrites. The urine culture grows >100,000 CFU/mL of Escherichia coli. Which of the following is the most appropriate next step in management?

A $78$-year-old man who resides in a skilled nursing facility is evaluated for acute-onset severe pain and swelling in his right knee that began $24$ hours ago. He has a history of hypertension, diet-controlled type 2 diabetes mellitus, and advanced chronic kidney disease with a baseline serum creatinine of $2.6 \text{ mg/dL}$. Vital signs are within normal limits except for a temperature of $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$). Physical examination reveals a warm, erythematous, and swollen right knee with a moderate effusion. Range of motion is severely limited by pain. Arthrocentesis yields $4 \text{ mL}$ of cloudy, yellow synovial fluid. Analysis shows a leukocyte count of $32,000/\mu\text{L}$ with $90\%$ neutrophils. Polarized light microscopy demonstrates rhomboid-shaped crystals with weak positive birefringence. Gram stain reveals no organisms. Which of the following is the most appropriate next step in management?

A male preterm neonate, born at $28$ weeks gestation and currently on day $12$ of life, is evaluated in the neonatal intensive care unit for new-onset lethargy and temperature instability. He had been tolerating gradually increasing volumes of fortified expressed breast milk via an orogastric tube. Vital signs show a temperature of $35.8^\circ\text{C}$ ($96.4^\circ\text{F}$), heart rate of $175/\text{min}$, respiratory rate of $68/\text{min}$, and blood pressure of $52/34\text{ mmHg}$. Physical examination reveals a mottled, hypoactive infant. The abdomen is markedly distended and visibly erythematous. The bedside nurse reports aspirating $15\text{ mL}$ of bilious residual fluid from the feeding tube. A scattered cutaneous eruption of $1\text{-}$ to $2\text{-mm}$ yellow pustules on an erythematous base is noted on the infant's thighs; a previous Wright stain of these lesions demonstrated a predominance of eosinophils.

An anteroposterior abdominal radiograph demonstrates dilated loops of bowel, linear radiolucencies within the bowel wall, and branching radiolucencies overlying the hepatic shadow. No free intraperitoneal air is visualized.

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