All practice questions

A 2-day-old male newborn is evaluated in the nursery for a newly developed skin rash. He was born at 39 weeks gestation via uncomplicated spontaneous vaginal delivery to a 28-year-old primigravid mother. Maternal prenatal laboratory testing, including group B Streptococcus screening, was negative. The infant has been breastfeeding well and stooling normally. Vital signs are temperature 36.8°C (98.2°F), heart rate 140/min, and respiratory rate 40/min. Physical examination reveals multiple erythematous macules and papules with small central pustules scattered across the trunk and proximal extremities. The palms and soles are spared. The infant is vigorous and in no apparent distress. Which of the following is the most appropriate next step in management?

A 2-year-old boy is brought to the emergency department by his parents due to a sudden onset of a harsh, barking cough and noisy breathing. On examination, he has inspiratory stridor at rest and moderate suprasternal retractions. He is currently crying and agitated, which appears to be worsening his respiratory distress. His oxygen saturation is 96% on room air. Arrange the following steps in the most appropriate clinical sequence for the acute management of this patient's condition.

A 41-year-old woman is evaluated in the emergency department for a 2-day history of severe epistaxis, easy bruising, and profound fatigue. Laboratory studies reveal a hemoglobin of $7.8 \text{ g/dL}$, a leukocyte count of $1,200/\mu\text{L}$, and a platelet count of $18,000/\mu\text{L}$. Coagulation studies show a prolonged prothrombin time, a prolonged activated partial thromboplastin time, a significantly elevated D-dimer, and a fibrinogen level of $85 \text{ mg/dL}$ (normal: $150-400 \text{ mg/dL}$). The patient is suspected to have acute promyelocytic leukemia (APL). Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for managing this patient.

Match each clinical presentation with the most likely rheumatologic diagnosis.

A $3$-hour-old male neonate is evaluated in the nursery for jitteriness, lethargy, and poor feeding. He was born at $39$ weeks gestation to a mother with poorly controlled type 2 diabetes mellitus. His birth weight was $4.5\text{ kg}$ ($9.9\text{ lb}$). Vital signs include a temperature of $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), heart rate of $150/\text{min}$, and respiratory rate of $45/\text{min}$. Physical examination reveals a markedly plethoric (ruddy) skin appearance. Small, firm, white nodules are noted on the alveolar ridges. A peripheral venous hematocrit is $72\%$. Capillary blood glucose is $52\text{ mg/dL}$. Which of the following is the most appropriate next step in management?

A 48-year-old man is hospitalized with a 1-week history of fever and severe lower back pain. He has a history of injection drug use. Temperature is 38.6°C (101.5°F), blood pressure is 120/75 mm Hg, and pulse is 98/min. Physical examination shows point tenderness over the lower lumbar spine. Neurologic examination is unremarkable. Magnetic resonance imaging of the spine reveals L3-L4 vertebral osteomyelitis and a small epidural abscess without cord compression. Empiric therapy with intravenous vancomycin and piperacillin-tazobactam is initiated. Two days later, blood cultures drawn at admission grow methicillin-susceptible Staphylococcus aureus (MSSA). The isolate is susceptible to oxacillin, cefazolin, and vancomycin. The patient's clinical status is stable. Which of the following is the most appropriate next step in pharmacotherapy?

A $14$-year-old male is brought to the clinic due to a $4$-week history of right knee pain and an altering gait. He has no history of trauma, fever, or recent illnesses. His weight is at the $98^{\text{th}}$ percentile for his age. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate of $78\text{/min}$, and blood pressure of $118/76\text{ mm Hg}$. Physical examination of the right knee reveals no effusion, joint line tenderness, or ligamentous laxity. During the examination of the lower extremities in the supine position, passive flexion of the right hip results in obligatory external rotation of the thigh. Laboratory studies show a leukocyte count of $6,800/\text{mm}^3$, an erythrocyte sedimentation rate of $8\text{ mm/h}$, and a C-reactive protein level of $0.3\text{ mg/dL}$. Which of the following is the most appropriate next step in management?

A $65$-year-old man is brought to the emergency department by his daughter due to a $24$-hour history of severe headache, fever, and progressive confusion. His temperature is $39.2^{\circ}\text{C}$ ($102.6^{\circ}\text{F}$), blood pressure is $118/76 \text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $18/\text{min}$. On physical examination, the patient is lethargic and oriented only to his name. He resists passive neck flexion. Pupils are equal and reactive to light, and there are no focal motor deficits. A purpuric rash is not present. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for this patient's management.

A $14$-day-old male infant is brought to the pediatric emergency department by his parents due to a fever noted at home. The parents report that he has been feeding slightly less than usual over the past $24$ hours but is producing a normal number of wet diapers. He was born at $38$ weeks gestation via uncomplicated spontaneous vaginal delivery. Maternal group B *Streptococcus* screening was negative. The mother reports no history of genital ulcers, although she does have a history of occasional oral cold sores. On physical examination, the infant is awake and alert. Vital signs show a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), heart rate of $160/\text{min}$, and respiratory rate of $42/\text{min}$. Skin examination reveals a cluster of $4$ small, erythematous vesicles on the right shoulder. The anterior fontanelle is flat, and the neurological examination is nonfocal. Laboratory studies show a peripheral leukocyte count of $12,500/\mu\text{L}$. Urinalysis is unremarkable. Which of the following is the most appropriate next step in management?

An infectious diseases consultation is requested for a 72-year-old man due to persistent fevers. He was admitted to the hospital 4 days ago with a 3-week history of malaise, low-grade fevers, and chills. These symptoms began approximately one month after he underwent a cystoscopy for benign prostatic hyperplasia. His medical history is notable for hypertension, type 2 diabetes mellitus, and stage 3 chronic kidney disease.

On physical examination, his temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $138/82\text{ mmHg}$, and pulse is $92\text{/min}$. Cardiac auscultation reveals a new grade $2/6$ diastolic decrescendo murmur heard best at the right upper sternal border. Examination of the hands shows small, linear, dark red streaks in the nail beds.

A transesophageal echocardiogram demonstrates a $1.2\text{-cm}$ mobile vegetation on the aortic valve with moderate aortic regurgitation. Four sets of blood cultures drawn upon admission are all positive for *Enterococcus faecalis*.

Antimicrobial susceptibility testing of the isolate shows the following:

Current laboratory results reveal a leukocyte count of $14,200/\text{mm}^3$ and a serum creatinine of $1.9\text{ mg/dL}$ (baseline $1.8\text{ mg/dL}$).

Which of the following is the most appropriate definitive intravenous antimicrobial regimen for this patient?

A 48-hour-old full-term male newborn develops bright green vomiting in the nursery. He was born via an uncomplicated vaginal delivery and passed meconium at 18 hours of life. His vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate 145/min, respiratory rate 42/min, and blood pressure 65/40 mm Hg. Physical examination shows a mildly distended but soft abdomen without erythema. The patient is hemodynamically stable. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence to evaluate and definitively manage the most critical time-sensitive etiology of this presentation.

A 65-year-old man is brought to the emergency department by his wife due to fever, severe headache, and progressive confusion for the past 12 hours. His temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and pulse is 115/min. Physical examination reveals nuchal rigidity, lethargy, and a new-onset left-sided pronator drift. Suspecting acute bacterial meningitis, arrange the following management steps in the most appropriate chronological order.

An unimmunized 4-year-old male child arrives at the pediatric triage with sudden-onset high fever, a muffled voice, and severe drooling. He is sitting upright, leaning forward with his neck extended, and exhibits notable inspiratory stridor. The clinical presentation is highly suspicious for acute epiglottitis. Arrange the following management steps in the most appropriate sequential order, from first to last.

An intensive care unit team is evaluating a 68-year-old man who was admitted four days ago for septic shock complicated by acute respiratory failure. The patient initially presented with a perforated diverticulum and underwent an emergency exploratory laparotomy. He is currently mechanically ventilated and receiving continuous intravenous norepinephrine. His medical history includes hypertension and benign prostatic hyperplasia.

Current vital signs are temperature 37.6°C (99.7°F), pulse 98/min, blood pressure 102/64 mmHg, and oxygen saturation 96% on a fraction of inspired oxygen of 0.40. Physical examination reveals a sedated patient with a healing midline abdominal incision.

Arterial blood gas analysis on current ventilator settings reveals:
- $pH$: 7.32
- $pCO_2$: 35 mmHg
- $pO_2$: 82 mmHg
- $HCO_3^-$: 18 mEq/L

Due to persistent vasopressor requirements, an endocrine evaluation is obtained, which shows:
- Thyroid-stimulating hormone (TSH): 0.2 $\mu$ U/mL (Normal: 0.4–4.0 $\mu$ U/mL)
- Free thyroxine (T4): 0.6 ng/dL (Normal: 0.9–1.7 ng/dL)
- Total triiodothyronine (T3): 40 ng/dL (Normal: 80–200 ng/dL)

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

A newborn is delivered at $38$ weeks gestation and immediately exhibits severe respiratory distress and cyanosis. Physical examination reveals a scaphoid abdomen and absent breath sounds over the left hemithorax. The neonate's heart rate is $110/\text{min}$, and oxygen saturation is $78\%$ on room air. Based on the suspected diagnosis, arrange the following management steps in the most appropriate chronological sequence.

A 68-year-old man is brought to the emergency department by his daughter due to a 24-hour history of fever, severe headache, and worsening confusion. He has a medical history of type 2 diabetes mellitus and hypertension. His temperature is 39.4°C (102.9°F), blood pressure is 105/65 mm Hg, pulse is 118/min, and respirations are 22/min. On physical examination, the patient is lethargic and oriented only to person. He has marked nuchal rigidity. Neurologic examination reveals a newly developed left-sided facial droop and left arm weakness. Funduscopic examination is limited due to poor patient cooperation.

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

An 8-week-old boy is brought to the pediatric clinic by his mother due to a 3-week history of severe nasal congestion and a skin rash. The mother reports that the infant has a thick, blood-tinged nasal discharge that frequently interferes with his ability to feed. A few days ago, a red, peeling rash appeared on the infant's extremities, distinctly involving the palms and soles. The infant was born at home in a rural setting, and the mother did not receive any formal prenatal care. On physical examination, the infant's temperature is 37.5°C (99.5°F), pulse is 145/min, and respirations are 38/min. The infant appears mildly fussy but easily consolable. Generalized lymphadenopathy and firm hepatosplenomegaly are palpable. The lungs are clear to auscultation bilaterally. Which of the following is the most appropriate next step in the management of this patient?

Match each pediatric infectious disease exposure scenario with the most appropriate post-exposure management or prophylaxis strategy.

Match each pediatric patient's clinical presentation or medical history with the most appropriate vaccine management decision.

A primary care network is developing an automated electronic medical record system to alert pediatricians about critical immunization milestones. Arrange the following immunization-related events in chronological order from the earliest age to the oldest age at which they are typically recommended to occur for a healthy pediatric patient following the standard CDC schedule.