All practice questions

An infant, aged 21 days, is evaluated at an urgent care clinic for a one-day history of noisy breathing, frequent cough, and nasal congestion. The mother notes the infant's 4-year-old sister recently stayed home from preschool with a cold. The infant was born at 39 weeks gestation via uncomplicated vaginal delivery. Vital signs show a temperature of 37.2°C (99.0°F), heart rate of 155/min, respiratory rate of 62/min, and oxygen saturation of 95% on room air. Physical examination reveals mild subcostal retractions, copious clear nasal discharge, and diffuse bilateral wheezes and crackles on auscultation. Skin examination shows scattered, well-demarcated erythematous macules with small central yellow pustules predominantly on the chest and back. Which of the following is the most appropriate next step in management?

A 65-year-old man is evaluated in the intensive care unit for recent fever. He was admitted 10 days ago for severe acute pancreatitis and required aggressive fluid resuscitation via a right internal jugular central venous catheter. Two days ago, he developed a temperature of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$) and tachycardia. The central catheter was removed, and peripheral blood cultures were drawn. Empiric intravenous vancomycin and cefepime were initiated. Today, the patient is afebrile and hemodynamically stable. Both sets of blood cultures are positive for *Enterococcus faecalis*. Susceptibility testing demonstrates that the isolate is susceptible to ampicillin, vancomycin, and daptomycin, but resistant to cefepime. Which of the following is the most appropriate next step in this patient's antimicrobial therapy?

A 52-year-old man is brought to the emergency department after vomiting a large volume of bright red blood. He has a known history of decompensated liver cirrhosis secondary to chronic hepatitis C infection. On arrival, his blood pressure is 85/50 mm Hg, and his heart rate is 124/min. He is lethargic but protecting his airway, with an oxygen saturation of 96% on room air. Physical examination reveals scleral icterus, spider angiomas, and a distended abdomen with shifting dullness. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $45$-year-old female teacher is brought to the emergency department by her husband after she was unable to get out of bed this morning due to severe, generalized muscle weakness. Over the past several years, she has experienced a persistent sensation of sand in her eyes and requires frequent sips of water to swallow dry food. She has no other medical conditions and takes no medications. On physical examination, her vital signs are within normal limits. Bilateral parotid gland enlargement is noted. Neuromuscular examination reveals symmetric $\frac{2}{5}$ motor strength in the proximal muscles of the upper and lower extremities. Deep tendon reflexes are diminished globally.

Laboratory results are as follows:

Arterial blood gas (room air):
pH: $7.25$
$\text{pCO}_2$: $26$ mm Hg
$\text{pO}_2$: $95$ mm Hg

Serum chemistry:
Sodium: $140$ mEq/L
Potassium: $2.1$ mEq/L
Chloride: $116$ mEq/L
Bicarbonate: $12$ mEq/L
Creatinine: $0.9$ mg/dL
Blood urea nitrogen: $14$ mg/dL

Urinalysis:
pH: $6.5$
Specific gravity: $1.015$
Glucose: negative
Protein: negative
Ketones: negative

Which of the following is the most likely underlying mechanism for this patient's clinical presentation?

An emergency department physician is evaluating a primigravida at $34$ weeks gestation who presents with a $2$-day history of gingival bleeding while brushing her teeth and a new rash on her legs. The $31$-year-old patient reports feeling otherwise well and has had uncomplicated prenatal care until now. She denies headache, visual changes, right upper quadrant pain, or uterine contractions. Fetal movement is active.

Vital signs are:
* Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
* Blood pressure: $118/76$ mmHg
* Heart rate: $88/\text{min}$
* Respiratory rate: $16/\text{min}$

Physical examination reveals a gravid, non-tender uterus and scattered petechiae over both lower extremities. Fetal heart rate monitoring is reassuring.

Laboratory results are as follows:

Peripheral blood smear demonstrates profoundly reduced platelet numbers with a few large platelets. No schistocytes or immature leukocytes are observed.

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

A 73-year-old woman presents to the emergency department reporting a sudden, painless loss of vision in her right eye that began two hours ago. Over the past week, she has experienced a persistent, severe, right-sided headache, fatigue, and pain in her jaw muscles when chewing. Physical examination reveals a tender, non-pulsatile right temporal artery. Laboratory studies show an erythrocyte sedimentation rate of $95$ mm/h. Arrange the following steps in the most appropriate chronological sequence for the standard diagnostic and therapeutic management of this patient's condition.

A 39-week gestation male neonate is delivered via emergency cesarean section due to sudden, massive maternal vaginal bleeding and fetal bradycardia (suspected placental abruption). Upon delivery, the neonate is apneic, cyanotic, and completely flaccid. The initial heart rate is 70/min.

Assuming the neonate's heart rate persistently falls and remains below 60/min despite adequate execution of each preceding intervention, arrange the following management steps in the correct chronological sequence according to the standard Neonatal Resuscitation Program (NRP) algorithm.

A term male neonate is delivered at $39$ weeks gestation via spontaneous vaginal delivery. The mother is a $24$-year-old primigravida who received limited prenatal care. Immediately after birth, the infant is apneic, cyanotic, and limp. His heart rate is $80/\text{min}$. Physical examination reveals a barrel-shaped chest and a scaphoid abdomen. Auscultation demonstrates absent breath sounds over the left hemithorax and heart sounds that are loudest over the right midclavicular line. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 12-day-old male infant is brought to the emergency department by his parents due to decreased oral intake, excessive sleepiness, and a new skin rash that developed 24 hours ago. He was born at 39 weeks of gestation via spontaneous vaginal delivery to a 24-year-old primigravida. A fetal scalp electrode was utilized during labor for continuous heart rate monitoring. The mother's prenatal course was uncomplicated, and her prenatal laboratory results were within normal limits. The infant's temperature is 38.6°C (101.5°F), heart rate is 170/min, and respiratory rate is 45/min. Physical examination reveals an ill-appearing, lethargic infant with a bulging anterior fontanelle and increased tone in all extremities. On the scalp, there are several small, clustered, fluid-filled vesicles on an erythematous base. Which of the following is the most appropriate next step in management?

A $35$-year-old man with a history of advanced HIV (CD4 count of $45 \text{ cells/mm}^3$) is brought to the emergency department by his partner due to $2$ days of fever, severe headache, and progressive confusion. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $110/70 \text{ mmHg}$, and pulse is $115/\text{min}$. Physical examination reveals nuchal rigidity and a positive Brudzinski sign. He is lethargic but withdraws all extremities to pain. Fundoscopic examination shows early papilledema. Suspecting acute bacterial meningitis, the physician decides on a management plan. Arrange the following steps in the most appropriate chronological order of execution for this patient.

A 28-year-old male with a 5-year history of schizophrenia is evaluated in the inpatient psychiatric unit for severe, persistent commanding auditory hallucinations and paranoid delusions. He is currently prescribed olanzapine 20 mg daily. His psychiatric history reveals a prior 8-week trial of risperidone 6 mg daily, which was discontinued due to a lack of efficacy. The patient insists he takes his medication every day as prescribed. The treatment team is evaluating him for treatment-resistant schizophrenia. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 64-year-old man is evaluated on the medical ward on hospital day 3. He was initially admitted for community-acquired pneumonia and was started on empiric therapy with intravenous ceftriaxone and oral azithromycin. Upon admission, he had a temperature of 38.6°C (101.5°F), a respiratory rate of 24/min, and a right lower lobe infiltrate on chest radiography.

Today, the patient reports significant improvement in his cough and shortness of breath. His temperature is 37.1°C (98.8°F), blood pressure is 122/78 mm Hg, pulse is 76/min, and respiratory rate is 16/min. Pulse oximetry shows 97% on room air. He is tolerating an oral diet well. Sputum culture obtained on admission has grown heavy *Streptococcus pneumoniae*. Susceptibility testing results are as follows:

Blood cultures have shown no growth after 72 hours. Which of the following is the most appropriate modification to this patient's pharmacologic management?

A 65-year-old man is brought to the emergency department due to profound weakness and lethargy. He has experienced large-volume, watery diarrhea for the past 5 days following a recent trip abroad. His medical history is significant for severe chronic obstructive pulmonary disease (COPD) requiring 2 L/min of home oxygen, and hypertension. Current medications include inhaled tiotropium, inhaled fluticasone-salmeterol, and lisinopril.

Temperature is 37.2°C (99.0°F), blood pressure is 98/60 mm Hg, pulse is 114/min, and respirations are 26/min. Physical examination shows dry mucous membranes, delayed capillary refill, and diffusely decreased breath sounds with a prolonged expiratory phase.

Laboratory studies show:
Serum sodium: 136 mEq/L
Serum potassium: 3.1 mEq/L
Serum chloride: 114 mEq/L
Serum bicarbonate: 12 mEq/L
Blood urea nitrogen: 48 mg/dL
Serum creatinine: 1.9 mg/dL

Arterial blood gas (on room air):
pH: 7.24
$PaCO_2$: 36 mm Hg
$PaO_2$: 62 mm Hg

Which of the following best characterizes this patient's acid-base disorder?

A 19-year-old female presents to the university clinic reporting two days of persistent nausea, subjective dizziness, and a continuous buzzing sensation in both ears. She also mentions breathing faster than normal over the last few hours. She recently had a severe viral upper respiratory infection and has been taking an over-the-counter medication for muscle aches and fever.

Vital signs are as follows:
Temperature: $37.2^\circ\text{C} (99.0^\circ\text{F})$
Blood pressure: $118/76 \text{ mmHg}$
Heart rate: $112/\text{min}$
Respiratory rate: $26/\text{min}$
Oxygen saturation: $99\%$ on room air

Which of the following best characterizes this patient's acid-base status?

A 52-year-old man is hospitalized for the treatment of newly diagnosed Burkitt lymphoma. Twenty-four hours after receiving his first dose of systemic chemotherapy, he reports weakness, severe muscle cramps, and nausea. His temperature is 37.2°C (99.0°F), blood pressure is 110/70 mm Hg, pulse is 105/min, and respirations are 16/min.

An electrocardiogram reveals peaked T waves and a prolonged PR interval. Which of the following is the most appropriate immediate next step in management?

A $42$-year-old man is diagnosed with a pheochromocytoma following evaluation for episodic headaches, diaphoresis, and severe hypertension. Elevated plasma fractionated metanephrines and an adrenal mass on magnetic resonance imaging (MRI) confirm the diagnosis. The patient is scheduled for surgical resection of the tumor. Arrange the following management steps in the correct mandatory chronological sequence to safely prepare this patient for surgery.

Emergency medical services bring a $21$-year-old male university student to the resuscitation bay after his roommate found him lethargic and vomiting in their dorm. The patient has a history of type 1 diabetes mellitus but ran out of his prescribed insulin three days ago. On initial assessment, he appears severely dehydrated and is taking deep, rapid breaths. Vital signs include a heart rate of $122/\text{min}$, blood pressure of $90/60 \text{ mm Hg}$, and respiratory rate of $28/\text{min}$. A point-of-care capillary glucose reads $520 \text{ mg/dL}$, and a venous blood gas reveals a pH of $7.12$ with a calculated anion gap of $22 \text{ mEq/L}$. The clinical team establishes large-bore peripheral intravenous access. Arrange the following therapeutic steps in the most appropriate chronological order for managing this patient's metabolic decompensation.

A 13-month-old girl is diagnosed with roseola infantum (exanthema subitum), a common childhood illness primarily caused by Human Herpesvirus 6 (HHV-6). Arrange the classic clinical events of this viral infection in the chronological order they typically occur.

A 16-day-old male infant is brought to the emergency department after experiencing a generalized tonic-clonic seizure lasting approximately two minutes. The parents report that he has been increasingly irritable and feeding poorly for the past 24 hours. The patient was born at 38 weeks of gestation via an uncomplicated vaginal delivery. Maternal prenatal screening was unremarkable, including a negative rectovaginal culture for Group B *Streptococcus* at 36 weeks.

On physical examination, the infant is lethargic with a rectal temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), heart rate of $175/\text{min}$, and respiratory rate of $55/\text{min}$. He has a full, tense anterior fontanelle. A sparse, non-pruritic, erythematous papular eruption with central pustules is noted on the trunk.

A lumbar puncture is performed, and the cerebrospinal fluid (CSF) analysis reveals the following:

The patient is promptly started on empiric antimicrobial therapy. Forty-eight hours later, the laboratory reports that the CSF culture is growing a non-spore-forming, Gram-positive bacillus that exhibits tumbling motility at room temperature.

Based on these findings, which of the following is the most appropriate targeted pharmacotherapy for this patient?

A $32$-year-old woman, gravida 2, para 1, at $16$ weeks gestation presents to the emergency department reporting profound and rapidly worsening muscle weakness. Over the past $48$ hours, she has found it increasingly difficult to climb stairs and this morning was unable to stand up from a seated position. Her medical history is notable for bilateral parotid gland enlargement and a chronic "gritty" sensation in her eyes, for which she frequently uses over-the-counter artificial tears. She also reports a history of multiple dental cavities despite good oral hygiene. Vital signs are within normal limits. Physical examination reveals flaccid paralysis of the proximal lower extremities with absent deep tendon reflexes. Sensory examination is normal. Laboratory findings show:

* Serum sodium: $140 \text{ mEq/L}$
* Serum potassium: $1.8 \text{ mEq/L}$
* Serum chloride: $118 \text{ mEq/L}$
* Serum bicarbonate: $12 \text{ mEq/L}$
* Blood urea nitrogen: $14 \text{ mg/dL}$
* Serum creatinine: $0.8 \text{ mg/dL}$
* Urine pH: $6.8$

Which of the following is the most likely mechanism responsible for this patient's acute presentation?