All practice questions

Evaluate the following pediatric patient scenarios and pair each with the single most appropriate targeted preventive care or immunization intervention.

Parents bring their 8-week-old male infant to the emergency department due to rapid breathing and poor weight gain. The mother reports that the infant has been struggling to finish his feeds over the past two weeks. During breastfeeding, he frequently breaks his latch, becomes visibly diaphoretic, and cries inconsolably. He has had no fevers, cough, or sick contacts. Vital signs reveal a temperature of 37.2°C (99.0°F), a heart rate of 165/min, and a respiratory rate of 65/min. Pulse oximetry is 96% on room air. On physical examination, the infant appears anxious with mild intercostal retractions and diffuse expiratory wheezes. Cardiac auscultation reveals a prominent grade 2/6 holosystolic murmur at the cardiac apex that radiates to the axilla. The liver edge is palpable 3.5 cm below the right costal margin. An electrocardiogram is obtained and demonstrates deep Q waves and ST-segment elevations in leads I, aVL, and V5-V6. Which of the following is the most likely underlying mechanism for this patient's current symptomatic deterioration?

A $9$-year-old boy is brought to the emergency department by his parents due to lethargy and recurrent vomiting for the past $24\text{ hours}$. Over the preceding two weeks, he has had increased thirst, frequent urination, and a $3\text{ kg}$ ($6.6\text{ lbs}$) weight loss. He has no significant past medical history.

On initial presentation, he is lethargic but arousable to verbal commands. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $90/55\text{ mmHg}$, pulse is $135/\text{min}$, and respiratory rate is $32/\text{min}$ with deep, rapid respirations. Mucous membranes are dry, and capillary refill is $4\text{ seconds}$.

Initial laboratory studies:
- Serum sodium: $132\text{ mEq/L}$
- Serum potassium: $4.8\text{ mEq/L}$
- Serum chloride: $98\text{ mEq/L}$
- Serum bicarbonate: $8\text{ mEq/L}$
- Serum glucose: $580\text{ mg/dL}$
- Arterial pH: $7.15$
- Arterial $pCO_2$: $22\text{ mmHg}$
- TSH: $0.4\text{ mIU/L}$ (Normal: $0.5-5.0\text{ mIU/L}$)
- Free T4: $0.8\text{ ng/dL}$ (Normal: $0.9-1.7\text{ ng/dL}$)

The patient receives a $20\text{ mL/kg}$ bolus of $0.9\%$ normal saline over $1\text{ hour}$. Subsequently, a continuous intravenous infusion of regular insulin is started at $0.1\text{ units/kg/hr}$ along with appropriate maintenance fluids containing potassium.

Four hours later, the nurse urgently calls the physician because the patient has become increasingly obtunded and is complaining of a severe, diffuse headache.

Current vital signs:
- Blood pressure: $140/90\text{ mmHg}$
- Pulse: $58/\text{min}$
- Respiratory rate: $16/\text{min}$

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

A 6-year-old boy is brought to the emergency department by ambulance due to ongoing generalized tonic-clonic movements. His mother reports the seizure began 20 minutes ago and has not stopped. He has a history of epilepsy but missed his medications for the past two days. Arrange the following management steps for this patient in the most appropriate chronological order according to standard pediatric status epilepticus protocols.

A previously healthy 6-year-old girl is evaluated in the outpatient pediatric clinic. Two days ago, she experienced her first unprovoked generalized tonic-clonic seizure, which lasted 3 minutes and was followed by a 20-minute postictal period. She has since returned to her baseline, and her neurologic examination today is completely unremarkable. Assuming she eventually develops a typical course of focal epilepsy, arrange the following clinical steps in the most appropriate chronological sequence for her longitudinal evaluation and management.

A 2-year-old girl is evaluated in the emergency department for refusal to move her right arm. Approximately three hours ago, she was holding hands with her older brother and suddenly tripped; the brother quickly pulled her up by the hand to prevent her from falling. Following this event, she began crying and has kept her right arm tucked against her torso. On physical examination, the patient's right elbow is held in slight flexion and the forearm is pronated. There is no visible ecchymosis, erythema, or localized edema. She exhibits marked resistance and distress upon attempted passive supination of the right forearm, but no focal tenderness is elicited over the clavicle, distal humerus, or wrist. Her vital signs are stable, including a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$) and a heart rate of $110/\text{min}$. Laboratory testing shows a leukocyte count of $7,500/\text{mm}^3$, an erythrocyte sedimentation rate (ESR) of $8\text{ mm/hr}$, and a C-reactive protein (CRP) level of $2\text{ mg/L}$. Which of the following is the most appropriate next step in management?

During a routine health maintenance visit, the parents of a 16-month-old boy express concern regarding his motor development. They report that he started walking independently at 15 months of age but appears highly uncoordinated. According to the parents, he falls several times a day, maintains a very wide stance, and holds both arms in the air with his elbows slightly bent while moving. They are worried about a potential neurologic disorder because the child's older cousin was recently evaluated for ataxia. The pregnancy and delivery were uncomplicated. The child has a vocabulary of six words and correctly points to his nose when asked. Vital signs are within normal limits. Neurologic examination reveals an alert, cooperative child walking with a wide base and arms in a high-guard position. Muscle tone, bulk, and strength are symmetric and normal throughout. Deep tendon reflexes are 2+ globally. When offered a toy, he reaches for it smoothly with no intention tremor. Which of the following is the most appropriate next step in management?

A $5$-month-old boy is brought to the pediatric clinic by his parents due to increasing fatigue during bottle feeds. The parents notice that he stops frequently to catch his breath and sweats profusely around his forehead while eating. His weight has dropped from the $40^{\text{th}}$ percentile at birth to the $5^{\text{th}}$ percentile currently. On physical examination, the infant is tachypneic with a respiratory rate of $62/\text{min}$. A loud, harsh, grade $4/6$ holosystolic murmur is audible across the precordium, loudest at the lower left sternal border. Auscultation of the lungs reveals diffuse fine crackles and scattered expiratory wheezes. The liver edge is palpable $4\text{ cm}$ below the right costal margin. Which of the following is the most appropriate initial pharmacologic intervention to address this patient's acute symptoms?

Match each classic clinical presentation of postpartum hemorrhage to its most likely underlying etiology.

A 10-year-old girl with a known diagnosis of cystic fibrosis is admitted to the pediatric ward for an acute pulmonary exacerbation. She presents with an increased productive cough, decreased exercise tolerance, and a 12% drop in her forced expiratory volume in 1 second ($FEV_1$) from baseline. She is started on intravenous antipseudomonal antibiotics. The respiratory therapist is preparing her daily airway clearance regimen, which involves multiple inhaled medications and physical modalities.

Arrange the following therapies in the correct physiological sequence they should be administered during a single treatment session to maximize airway clearance and drug deposition.

Match each pediatric patient's clinical presentation with the most likely musculoskeletal diagnosis.

An infant is born with a large, unrestrictive ventricular septal defect (VSD). At birth, the infant is asymptomatic and has a normal physical examination. Arrange the following pathophysiologic and clinical events in the correct chronological sequence that typically leads to the development of symptomatic heart failure over the first 4 to 8 weeks of life.

A 23-year-old woman presents to the clinic with a 4-day history of a copious, malodorous vaginal discharge and mild vulvar itching. She is sexually active with a new male partner and uses oral contraceptive pills consistently. Her temperature is 37.1°C (98.8°F), blood pressure is 110/70 mmHg, and pulse is 76/min. Pelvic examination reveals a frothy, yellow-green discharge in the vaginal vault and punctate macular hemorrhages on the cervix. Vaginal pH is measured at 6.0. Wet mount microscopy demonstrates numerous motile, flagellated organisms slightly larger than polymorphonuclear leukocytes. Which of the following is the most appropriate pharmacotherapy for this patient?

A 32-year-old G3P3 at 39 weeks gestation experiences brisk, continuous vaginal bleeding immediately following an uncomplicated spontaneous vaginal delivery of a 4,300 g (9 lb 8 oz) neonate. The placenta delivers spontaneously and appears intact. On physical examination, the uterus is soft, boggy, and palpated above the umbilicus. Vital signs show a blood pressure of 90/55 mmHg and a heart rate of 118/min. Two large-bore intravenous lines are established, fluid resuscitation is initiated, and a Foley catheter is placed to empty the bladder.

Arrange the following interventions in the correct escalating sequence for the management of postpartum hemorrhage secondary to uterine atony, assuming continued bleeding at each step and no medical contraindications.

A 58-year-old female presents to the clinic to discuss the results of recent imaging. Two weeks prior, she reported a single episode of blood-tinged vaginal discharge. She underwent menopause at age 50 and takes no medications. A transvaginal ultrasound was subsequently ordered, which demonstrates an endometrial stripe thickness of $9$ mm. Today, her vital signs are within normal limits. Speculum examination reveals a normal-appearing cervix with no active bleeding. Which of the following is the most appropriate next step in the management of this patient?

Match the following gynecologic infections with their classic clinical and laboratory findings.

A 23-year-old G1P0 woman at 39 weeks gestation is evaluated in the labor unit. She is currently 6 cm dilated and 90% effaced. The fetus is in a vertex presentation at 0 station. Continuous external fetal monitoring reveals a baseline heart rate of 145/min with moderate variability. During the assessment, recurrent gradual decelerations to 130/min are noted. The onset, nadir, and recovery of each deceleration exactly coincide with the beginning, peak, and end of the mother's uterine contractions, respectively. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation of secondary amenorrhea with the most likely underlying pathophysiological mechanism.

Match the following fetal heart rate (FHR) monitoring patterns observed during labor to their classic underlying pathophysiologic etiologies.

Evaluate the following patient scenarios involving severe pregnancy-related complications and pair each clinical presentation with its most accurate diagnostic condition.