All practice questions

An emergency medicine physician evaluates a 45-year-old immigrant male who complains of a 6-week history of productive cough, intermittent hemoptysis, drenching night sweats, and unintentional weight loss. The triage nurse notes a temperature of 38.2°C (100.8°F). The patient hands the physician a chest radiograph taken earlier today at an urgent care center, which reveals a prominent cavitary lesion in the right upper lobe. Arrange the following management steps in the most appropriate chronological order for this patient.

A 42-year-old man presents to the clinic with a 2-day history of a progressively spreading red, swollen, and tender area on his right lower extremity. He recalls scratching a mosquito bite in the same location a few days prior. He has no significant past medical history and takes no medications. Vital signs are temperature 37.3°C (99.1°F), blood pressure 124/76 mmHg, pulse 82/min, and respirations 14/min. Physical examination reveals a 10-cm area of diffuse erythema, warmth, and induration on the right shin. The borders of the erythema are indistinct. There is no palpable fluctuance, purulent drainage, ulceration, or crepitus. Peripheral pulses and distal sensation are intact. Which of the following is the most appropriate empiric pharmacotherapy for this patient?

Match each classic clinical description of a benign neonatal skin finding to its correct diagnosis.

A 26-year-old woman comes to the clinic reporting a 3-day history of a burning sensation with urination and increased urinary frequency. She has no fever, chills, flank pain, nausea, or vaginal discharge. Her temperature is $37.1^\circ C$ ($98.8^\circ F$), blood pressure is $118/76$ mm Hg, and pulse is $74$/min. Physical examination reveals mild suprapubic tenderness but no costovertebral angle tenderness. A urine dipstick test is positive for nitrites and leukocyte esterase. A urine pregnancy test is negative. Which of the following is the most appropriate empiric pharmacotherapy for this patient?

A $3$-day-old female infant, born at $35$ weeks and $4$ days gestation via emergency cesarean delivery for non-reassuring fetal heart tones, is evaluated in the neonatal intensive care unit for a newly developed skin eruption. Her mother had prolonged rupture of membranes for $22$ hours prior to delivery, and maternal Group B Streptococcus status was unknown. The infant's APGAR scores were $7$ and $8$ at $1$ and $5$ minutes, respectively. Birth weight was $2450\text{ g}$. She is currently feeding adequately through an orogastric tube and is maintaining oxygen saturations of $98\%$ on room air. Current vital signs are: temperature $37.1^\circ \text{C}$ ($98.8^\circ \text{F}$), heart rate $142/\text{min}$, respiratory rate $44/\text{min}$, and blood pressure $62/40\text{ mm Hg}$. Physical examination reveals a widespread rash consisting of superficial $1$- to $2\text{-mm}$ vesicopustules that strictly lack a surrounding erythematous halo. The lesions are prominent on the forehead, anterior neck, and lower back. Gentle wiping of a ruptured pustule reveals a small, collarette-like scale enclosing a hyperpigmented macule. A complete blood count reveals a leukocyte count of $22,000/\text{mm}^3$ with $55\%$ segmented neutrophils, $8\%$ band neutrophils, and $30\%$ lymphocytes. A Wright-stained smear of the pustular contents demonstrates numerous polymorphonuclear leukocytes but no organisms. Based on this patient's clinical presentation, which of the following is the most appropriate next step in management?

A toddler is evaluated at the pediatric clinic for a health maintenance visit at 15 months of age. His mother reports that he has been doing well since a hospitalization 5 months ago. At that time, he presented with 6 days of high fever, bilateral nonexudative conjunctivitis, erythema of the oral mucosa, and a generalized maculopapular rash. He was successfully treated in the hospital and discharged home. The patient currently takes daily low-dose aspirin and has no other medical conditions. He previously received all routine immunizations up to 6 months of age, but has not received any vaccines since then. His temperature is 37.1 C (98.8 F), blood pressure is 90/55 mm Hg, pulse is 110/min, and respirations are 24/min. Physical examination today is unremarkable. Which of the following is the most appropriate immunization plan for this patient today?

An 8-month-old male infant is evaluated in the pediatric clinic in late January for a 3-day history of nasal congestion, clear rhinorrhea, and a low-grade fever. Over the past 24 hours, he has developed a harsh cough and increased work of breathing. He has no significant past medical history and is fully vaccinated for his age. Vital signs show a temperature of 37.8°C (100.0°F), heart rate of 145/min, respiratory rate of 55/min, and oxygen saturation of 96% on room air. Physical examination reveals an alert, well-perfused infant with mild intercostal retractions, flared nostrils, and diffuse bilateral expiratory wheezes with prolonged expiration. There is no focal consolidation or crackles. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old man is hospitalized for symptomatic anemia and is receiving a transfusion of packed red blood cells. Thirty minutes into the transfusion, he develops severe chills, flank pain, and shortness of breath. His temperature is 39.1°C (102.4°F), blood pressure is 85/50 mm Hg, and heart rate is 115/min. The urine in his Foley catheter tubing suddenly appears dark red. An acute hemolytic transfusion reaction is suspected.

Arrange the following management steps in the most appropriate, evidence-based sequential order for this patient.

A 24-year-old primigravida at $18$ weeks gestation presents to the obstetric clinic with a painless, indurated ulcer on her right labium majus that appeared one week ago. She has bilateral inguinal lymphadenopathy. Rapid plasma reagin (RPR) testing is reactive at a titer of $1:32$, and fluorescent treponemal antibody absorption (FTA-ABS) testing is positive. The patient reports a well-documented history of anaphylaxis to amoxicillin in childhood, characterized by severe wheezing, facial swelling, and hypotension requiring epinephrine. She is otherwise healthy and takes a daily prenatal vitamin. Vital signs are within normal limits, and fetal heart tones are $145$/min.

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

A 41-week gestation neonate is born via emergency cesarean delivery for prolonged fetal bradycardia. The amniotic fluid is thickly stained with meconium. At birth, the infant is apneic, completely flaccid, and has a heart rate of 70/min. Assuming the infant's condition persistently deteriorates and fails to improve at each standard reassessment interval, arrange the following steps of neonatal resuscitation in the correct chronological sequence of execution according to current guidelines.

A 20-year-old college student presents to the emergency department with a 12-hour history of severe headache, fever, and neck stiffness. Her temperature is 39.2°C (102.6°F), blood pressure is 110/70 mm Hg, and pulse is 112/min. She is fully alert and oriented. Neurologic examination reveals a positive Brudzinski sign. There are no focal neurologic deficits, and fundoscopic examination shows no evidence of papilledema. She has no history of immunocompromise and no significant past medical history. What is the most appropriate chronological sequence for the following management steps?

A 62-year-old woman is evaluated in the emergency department for progressive dyspnea, a dry cough, and profound fatigue over the past $4$ months, which have acutely worsened over the last week. She also reports significant morning stiffness in her hands and wrists lasting up to $3$ hours, along with intermittent joint swelling for the past $6$ months. Her temperature is $37.4^\circ$ C ($99.3^\circ$ F), blood pressure is $142/88$ mmHg, pulse is $96$/min, respiratory rate is $22$/min, and oxygen saturation is $92\%$ on room air. Examination shows bilateral boggy swelling and tenderness of the metacarpophalangeal and proximal interphalangeal joints. Lung auscultation reveals fine crackles at both lung bases. There is no jugular venous distention, $S_3$ gallop, or peripheral edema.

Laboratory studies show:
Thyroid-stimulating hormone (TSH): $1.2$ $\mu$ U/mL (Normal: $0.4-4.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.6$ ng/dL (Normal: $0.9-1.7$ ng/dL)

An arterial blood gas on room air shows $pH = 7.48$, $PaCO_2 = 30$ mmHg, $PaO_2 = 65$ mmHg, and $HCO_3^- = 22$ mEq/L.
Chest radiograph shows diffuse, fine reticular opacities predominantly in the lower lung zones without cardiomegaly or pleural effusions.

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

An $11$-month-old female infant arrives at the pediatric emergency department during late autumn accompanied by her parents. They report she has had a low-grade fever, severe nasal congestion, and a progressively worsening cough for the past four days. Over the last $12$ hours, she has been unusually lethargic and has completely refused all bottle feedings. Her medical history is notable for severe atopic dermatitis, and her biological father has severe persistent asthma. Vital signs include a temperature of $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), heart rate of $165/\text{min}$, and respiratory rate of $72/\text{min}$. Oxygen saturation is $88\%$ on room air. Physical examination reveals an infant in significant respiratory distress, demonstrating nasal flaring, head bobbing, and marked subcostal retractions. Lung auscultation reveals widespread fine crackles and high-pitched expiratory wheezes bilaterally. Capillary refill time is $2$ seconds. The patient is immediately placed on high-flow supplemental oxygen, which improves her oxygen saturation to $95\%$. Which of the following is the most appropriate next step in the management of this patient?

Match each pediatric patient scenario involving an infectious exposure or specific risk factor with the most appropriate immediate preventive care intervention or post-exposure prophylaxis.

A 10-day-old neonate is evaluated in the emergency department for a fever of 38.4°C (101.1°F) and a new-onset vesicular rash concerning for neonatal herpes simplex virus infection. The first-year pediatric resident, nearing the end of a demanding 24-hour shift, decides to initiate intravenous acyclovir. While calculating the weight-based dose, the resident inadvertently misplaces a decimal point, ordering ten times the appropriate amount. The hospital's electronic prescribing system lacks a maximum dose alert for pediatric patients, and both the clinical pharmacist and the bedside nurse process the order without identifying the discrepancy. The neonate receives the massive dose and subsequently develops acute kidney injury, which resolves fully after several days of aggressive intravenous hydration. The following morning, upon realizing the error, the resident immediately files a report in the hospital's safety system, informs the attending physician, and expresses profound guilt and distress over the event. According to the principles of a "Just Culture," which of the following is the most appropriate institutional response to this adverse event?

A 4-year-old girl is brought to the emergency department with a 1-day history of fever and severe right knee pain. She refuses to bear weight on her right leg. Her temperature is 39.0°C (102.2°F), heart rate is 130/min, and blood pressure is 95/60 mm Hg. Physical examination reveals an erythematous, warm, and exquisitely tender right knee with a palpable effusion. Range of motion is severely restricted due to pain. Arrange the following steps in the most appropriate chronological sequence for the diagnosis and management of this patient's suspected septic arthritis.

A 72-year-old woman is evaluated on hospital day 3. She was initially admitted for progressively worsening shortness of breath and bilateral lower extremity swelling. Her medical history is significant for chronic obstructive pulmonary disease, type 2 diabetes mellitus, and essential hypertension. On admission, she was afebrile, with a blood pressure of $152/88$ mmHg, heart rate of $88$/min, and respiratory rate of $20$/min. Physical examination revealed jugular venous distention, bibasilar crackles, and scattered expiratory wheezing. An indwelling urinary catheter was placed to strictly monitor fluid output, and intravenous furosemide was initiated. Over the last $72$ hours, she has had excellent diuresis resulting in a $4.5$-kg ($9.9$-lb) weight loss, and her dyspnea has completely resolved. She currently breathes comfortably on room air. A urine culture sent on admission due to a cloudy appearance now grows $>100,000$ CFU/mL of *Escherichia coli*. The patient reports no suprapubic pain, flank pain, or dysuria. Her current temperature is $37.0^\circ$ C ($98.6^\circ$ F). Which of the following is the most appropriate next step in management?

A mother brings her 12-month-old son to the pediatrician for a scheduled health maintenance examination. He underwent a hepatic transplantation at 8 months of age due to biliary atresia and is currently maintained on an immunosuppressive regimen of oral tacrolimus and mycophenolate mofetil. His vital signs are within normal limits, and the physical examination is unremarkable. His mother reports that he is able to pull himself up to a standing position and cruise along furniture, but she expresses concern because he is not yet walking independently. He uses a neat pincer grasp to eat small pieces of food and speaks three specific words: "mama," "dada," and "ball." Medical records indicate he received all routine childhood immunizations precisely on schedule through his 6-month visit. Which of the following is the most appropriate management regarding this patient's care today?

During a routine well-child evaluation, the parents of a 21-day-old boy express concern regarding a progressive skin eruption on his face that began five days ago. The infant was born at 39 weeks gestation via uncomplicated spontaneous vaginal delivery to a 28-year-old primigravida. His birth weight was 3.4 kg (7 lb 8 oz), and Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The mother received standard prenatal care, and maternal group B Streptococcus screening was negative. The parents report that the infant is exclusively breastfed, latching well, and stooling normally without any episodes of emesis. He has had no fevers, irritability, or changes in his level of activity. Vital signs today show a rectal temperature of 37.1°C (98.8°F), heart rate of 135/min, and respiratory rate of 40/min. Physical examination reveals an alert, vigorous, and well-hydrated neonate. Skin examination is notable for numerous small, erythematous inflammatory papules and pustules strictly confined to the forehead, nose, and bilateral cheeks. There are no comedones present. The scalp, neck, trunk, and extremities remain clear. Which of the following is the most appropriate next step in management?

A mother brings her $3$-week-old son to the pediatric clinic due to a newly developed facial rash. The infant was delivered at full term without any maternal or fetal complications. He is exclusively breastfed, has normal urine and stool output, and is gaining weight appropriately. The infant's temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), pulse is $130/\text{min}$, and respirations are $32/\text{min}$. Physical examination reveals multiple scattered erythematous papules and pustules confined strictly to the cheeks, chin, and forehead. No open or closed comedones are observed. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate next step in management for this patient?