All practice questions

A 68-year-old man with a history of metastatic prostate cancer presents to the emergency department with 2 days of progressively worsening lower back pain and new-onset bilateral leg weakness. He also reports difficulty initiating urination for the past 12 hours. Vital signs are within normal limits. Physical examination reveals reduced motor strength (3/5) in both lower extremities, hyperreflexia at the knees and ankles, and decreased sensation to pinprick below the umbilicus. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 68-year-old man is evaluated in the hospital on day 3 of admission for community-acquired pneumonia. His medical history is significant for hypertension and osteoarthritis. On admission, he presented with a temperature of 38.9°C (102.0°F), a productive cough, and a right lower lobe consolidation on chest radiography. He was started on empiric therapy with intravenous ceftriaxone and oral azithromycin.

Sputum and blood cultures obtained on admission have now finalized, both growing *Streptococcus pneumoniae*. Susceptibility testing of the isolate demonstrates the following:

Today, the patient reports feeling much better. He has been afebrile for the past 28 hours. His heart rate is 78/min, blood pressure is 128/82 mmHg, and respiratory rate is 16/min. Oxygen saturation is 96% on room air. He is tolerating a regular diet without difficulty. Which of the following is the most appropriate next step in his antimicrobial management?

A 24-year-old man presents to the clinic evaluating a 10-month history of insidious-onset lower back pain. He notes that the pain is worst upon awakening, is accompanied by profound stiffness lasting up to two hours, and significantly improves after physical activity. He has no other medical conditions and takes no medications. His vital signs are within normal limits. Physical examination reveals tenderness to palpation over the sacroiliac joints and reduced forward flexion of the lumbar spine (abnormal modified Schober test).

Arrange the following interventions in the correct chronological sequence for the standard diagnostic workup and stepwise medical management of this patient's suspected condition. Assume that initial diagnostic imaging is inconclusive (necessitating a more sensitive modality to confirm the diagnosis) and that the patient later requires escalation of maintenance therapy due to an inadequate clinical response to first-line pharmacotherapy.

Match each neonatal respiratory condition with its classic clinical presentation and chest radiograph findings.

An adult female patient is evaluated in the acute care clinic approximately $1$ hour following the intentional ingestion of a large, unknown quantity of acetaminophen. On initial assessment, she is fully alert, cooperative, and reports no symptoms. Hemodynamic parameters are stable. Arrange the following clinical interventions in the most appropriate chronological sequence for the evaluation and treatment of this patient.

Match each patient's clinical presentation with the most appropriate first-line pharmacotherapy.

A 61-year-old man is brought to the emergency department due to a three-day history of progressively worsening breathlessness, orthopnea, and a cough productive of clear sputum. His past medical history is significant for severe chronic obstructive pulmonary disease (COPD), ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, and diet-controlled type 2 diabetes mellitus. Vital signs show a temperature of $37.1^\circ$ C ($98.8^\circ$ F), pulse of 112/min, blood pressure of 155/92 mm Hg, and respiratory rate of 26/min. Pulse oximetry demonstrates an oxygen saturation of $86\%$ on room air. Physical examination reveals neck veins distended to 11 cm $H_2O$ while the patient is seated at a 45-degree angle. Auscultation of the lungs demonstrates prominent bibasilar crackles without any wheezing. Cardiac examination reveals a regular tachycardia and an $S_3$ gallop. The lower extremities exhibit $2+$ pitting edema bilaterally.

Laboratory results are as follows:

An arterial blood gas on room air shows a pH of 7.26, a $PaCO_2$ of 65 mm Hg, and a $PaO_2$ of 52 mm Hg.

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

A 5-year-old girl is brought to the pediatric clinic for a well-child visit prior to starting kindergarten. She was diagnosed with polyarticular juvenile idiopathic arthritis two years ago and is currently maintained on a regimen of methotrexate and etanercept. The patient's mother states that the child has not received any immunizations since her 2-year-old well-child visit. She has no other medical conditions and takes no other medications. Vital signs are within normal limits. Physical examination shows no active joint swelling, warmth, or limitation in range of motion. Which of the following is the most appropriate immunization plan for this patient?

A 15-month-old boy is brought to the clinic for a routine well-child visit. He has not been evaluated by a physician since his 6-month visit because his family relocated. At 10 months of age, he was hospitalized for 5 days with a prolonged high fever, bilateral nonexudative conjunctivitis, mucosal changes, and unilateral cervical lymphadenopathy. Echocardiography at that time showed normal coronary arteries. He was treated successfully with high-dose aspirin and a single infusion of intravenous immunoglobulin (IVIG). He currently takes no medications. Developmentally, he walks independently and uses three specific words. He lives with his parents and a 4-year-old sister who is receiving maintenance chemotherapy for acute lymphoblastic leukemia. His immunization records indicate he received all recommended vaccinations at 2, 4, and 6 months of age. Which of the following is the most appropriate next step in management?

A 62-year-old woman is evaluated for progressively worsening fatigue and dyspnea on exertion over the past 3 months. She has followed a strict vegan diet for the past 5 years and does not take any nutritional supplements. Physical examination reveals pale conjunctivae, a smooth and red tongue, and decreased vibratory sensation in the lower extremities bilaterally. Laboratory studies show:

Which of the following additional laboratory findings is most likely to be present in this patient?

Identify the correct underlying neonatal respiratory pathology that corresponds to each of the distinct patient scenarios presented.

Match each clinical presentation involving the hands and joints to the most likely rheumatologic diagnosis.

A 54-year-old man comes to the office due to worsening redness and swelling of his left lower leg over the past 48 hours. He reports no fever, chills, or systemic symptoms. His medical history includes hypertension and diet-controlled type 2 diabetes mellitus. Vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 130/80 mm Hg, and heart rate of 78/min. Physical examination of the left lower extremity reveals a 10-cm area of poorly demarcated erythema, warmth, and tenderness over the anterior shin. There is no fluctuance, purulent drainage, or palpable fluid collection. Which of the following is the most appropriate antibiotic therapy?

A 15-year-old girl is brought to the clinic by her adoptive parents for an initial health evaluation. She was recently adopted from a developing country and has no available medical or immunization records. The patient has a known history of perinatally acquired HIV infection but has not consistently taken antiretroviral therapy in the past year. She has no acute complaints today and feels well. Her temperature is 37.1°C (98.8°F), blood pressure is 110/70 mm Hg, pulse is 82/min, and respirations are 14/min. Physical examination reveals mild generalized cervical and axillary lymphadenopathy but is otherwise unremarkable. Laboratory studies show an absolute CD4 T-lymphocyte count of 120 cells/mm³ (8% of total lymphocytes) and an HIV viral load of 150,000 copies/mL. Which of the following is the most appropriate immunization plan for this patient today?

A 34-year-old unhoused man is brought to the emergency department by paramedics after being found in severe distress in an alleyway. He sustained a deep puncture wound to his right sole from a rusty metal fence approximately 8 days ago. He has no known medical history, and his childhood vaccination status is unknown. On arrival, he is diaphoretic, tachycardic to 122/min, and tachypneic to 26/min. Physical examination reveals profound trismus, a sustained grimace of the facial muscles, and episodic, painful spasms of the paraspinal musculature that are immediately triggered by the noise of a dropping tray in the trauma bay. The right foot shows a 3-cm deep, purulent puncture wound surrounded by necrotic tissue.

Arrange the following therapeutic interventions in the most appropriate chronological sequence for the management of this patient's condition.

A female infant, chronologically 6 months of age, is evaluated during a routine health maintenance visit. She was delivered prematurely at 28 weeks gestation following a maternal placental abruption. The parents express significant concern regarding her development. They report that their older child, who was born at term, was able to sit without support and pass toys from one hand to the other by this age, whereas this patient is unable to perform these actions. During the physical examination, the infant visually tracks a brightly colored toy past the midline, coos in response to the physician's voice, and demonstrates a social smile. When placed in the prone position, she lifts her head and chest while resting on her forearms. When pulled to a sitting position, a very slight head lag is noted. Muscle tone and deep tendon reflexes are within normal limits. Which of the following is the most appropriate next step in the management of this patient?

A 74-year-old woman is evaluated in the emergency department for the sudden onset of extensive ecchymoses over her trunk and a large, expanding hematoma on her right thigh. She has no prior personal or family history of bleeding disorders. Her past medical history is significant for rheumatoid arthritis. Vital signs are within normal limits. Laboratory studies reveal a hemoglobin of 9.4 g/dL, platelet count of 250,000/mm³, prothrombin time (PT) of 12.5 seconds (normal: 11-15 sec), and activated partial thromboplastin time (aPTT) of 78 seconds (normal: 25-35 sec). Thrombin time is normal.

Arrange the following diagnostic steps in the correct chronological sequence required to definitively diagnose and fully characterize this patient's underlying hemostatic disorder.

During morning rounds on the inpatient hematology unit, a resident assesses a 38-year-old male who was admitted four days ago with a new diagnosis of acute promyelocytic leukemia. He was immediately started on targeted induction therapy including a vitamin A derivative. Over the last 12 hours, the patient has developed a fever, progressive shortness of breath, and a weight gain of $3.5\text{ kg}$. Temperature is $38.5^\circ\text{C}$ ($101.3^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows $89\%$ on ambient air. Physical examination reveals elevated jugular venous pressure and diffuse bilateral crackles on lung auscultation. Laboratory studies show a leukocyte count of $28,000/\mu\text{L}$, which has increased from $4,500/\mu\text{L}$ on admission. A chest radiograph demonstrates bilateral interstitial opacities and a small right-sided pleural effusion. Which of the following is the most appropriate next step in management?

A pediatrician is evaluating several pediatric patients who recently immigrated and have no prior immunization records. To establish appropriate catch-up schedules, the physician must identify which vaccines are no longer indicated based solely on each child's current age. Arrange the following vaccine doses in chronological order based on the strictly defined MAXIMUM age limit at which they can be administered to a healthy, immunocompetent child, from the youngest maximum age cut-off to the oldest.

A 3-week-old female infant is brought to the pediatric clinic by her parents because of a new rash on her face. The parents first noticed the skin changes three days ago, and they have gradually increased in number. The mother had an uncomplicated pregnancy and a spontaneous vaginal delivery at 39 weeks of gestation. The infant is exclusively breastfed, feeds vigorously every 2 to 3 hours, and produces 6 to 8 wet diapers daily. Her temperature is 37.0°C (98.6°F), heart rate is 130/min, and respiratory rate is 35/min. Physical examination reveals multiple scattered erythematous papules and pustules confined to the infant's cheeks, forehead, and chin. No open or closed comedones are observed. The trunk and extremities are clear. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate next step in management?