All practice questions

Match each complex puerperal complication described in the clinical vignette to its precise pathophysiologic mechanism and cornerstone of management.

Parents arrive at the emergency department with their 5-month-old male infant after he experienced a 2-minute episode of generalized extremity stiffening and rhythmic jerking. The parents report that he has been increasingly lethargic over the past 48 hours. During the history, they express concern that he is not yet able to sit up without support. Physical examination reveals a lethargic infant with generalized hypotonia and sparse scalp hair. A prominently erythematous, scaling rash with skin peeling is noted around his mouth and eyes. Vital signs show a heart rate of 152/min and a respiratory rate of 50/min.

Laboratory evaluation reveals the following:

Which of the following is the most appropriate specific treatment for this patient's underlying condition?

A 24-year-old woman comes to the clinic to discuss contraceptive options. She is sexually active with a new male partner and does not desire pregnancy. The patient has a history of severe, throbbing headaches that occur once a month. Before the onset of the headache, she typically sees a "flashing zigzag line" that slowly moves across her field of vision. She has no other medical conditions and takes no daily medications. Her blood pressure is 118/76 mm Hg, and body mass index is 22 kg/m². Which of the following contraceptive methods is absolutely contraindicated in this patient?

Parents bring their 24-month-old daughter to the emergency department because she has been refusing to stand or walk for the past 48 hours. They also report that she developed new-onset urinary incontinence this morning. The patient appears irritable but is consolable. Temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $115/70\text{ mmHg}$, and heart rate is $120\text{/min}$. Physical examination reveals a firm, irregular, palpable abdominal mass crossing the midline. Neurologic examination of the lower extremities shows $2/5$ motor strength bilaterally, $3+$ patellar and Achilles deep tendon reflexes, and a positive Babinski sign bilaterally. Anal sphincter tone is decreased.

Based on the most likely diagnosis, arrange the following management steps in the most appropriate chronological order of execution.

Seeking evaluation at a community health clinic, a $32$-year-old woman (G2P2) reports a $3$-day history of continuous, dull bilateral lower abdominal pain accompanied by new-onset malodorous vaginal discharge. She states she has been in a new monogamous sexual relationship for the past $2$ months. Her medical history is unremarkable, and she uses a copper intrauterine device (IUD) that was placed $3$ years ago for contraception. Vital signs show a blood pressure of $118/76\text{ mmHg}$, a pulse of $88\text{/min}$, and a temperature of $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$). Speculum examination reveals a normal-appearing cervix with visible IUD strings and thick, yellowish-green mucopurulent discharge at the cervical os. Bimanual examination elicits significant cervical motion tenderness as well as bilateral adnexal tenderness without palpable masses. A urine pregnancy test is negative. Pelvic ultrasound confirms the IUD is appropriately positioned within the endometrial cavity and demonstrates normal-appearing ovaries with no complex fluid collections or tubo-ovarian abscesses. The patient tolerates oral fluids without difficulty. Which of the following is the most appropriate next step in management?

A 25-year-old primigravid woman at 29 weeks gestation is evaluated in the obstetric clinic for a three-day history of right-sided flank discomfort. She describes the sensation as a mild, constant ache. She reports increased urinary frequency over the past month but specifically denies dysuria, hematuria, fever, chills, or nausea. Her temperature is 37.0°C (98.6°F), blood pressure is 114/72 mmHg, heart rate is 84/min, and respiratory rate is 16/min. Physical examination shows a gravid, non-tender abdomen with a fundal height of 29 cm. There is no costovertebral angle tenderness. A clean-catch urinalysis is negative for leukocyte esterase, nitrites, and blood. Due to the patient's persistent concern, a renal ultrasound is performed, revealing moderate dilation of the right renal pelvis and proximal ureter that tapers smoothly at the pelvic brim. The left kidney and ureter appear normal. No echogenic shadowing structures are seen. Which of the following is the most appropriate next step in management?

A $2$-year-old girl is brought to the emergency department by her parents because of noisy breathing and a harsh cough. Her symptoms began two days ago with a runny nose, mild congestion, and a low-grade fever. Last night, she developed a loud, "barking" cough and her voice became hoarse. Over the past $2$ hours, her parents noticed a high-pitched noise when she breathes in, even when she is sitting quietly in her mother's lap. Her temperature is $38.2^{\circ}\text{C}$ ($100.8^{\circ}\text{F}$), pulse is $142/\text{min}$, and respirations are $42/\text{min}$. Pulse oximetry is $96\%$ on room air. The patient is up-to-date on all childhood immunizations. On physical examination, the child is alert but appears anxious. There is noticeable inspiratory stridor at rest, accompanied by suprasternal and intercostal retractions. She is not drooling, and her oropharynx is clear without erythema or exudate. Auscultation of the lungs reveals transmitted upper airway sounds but no wheezing or crackles. Which of the following is the most appropriate next step in management?

A 29-year-old G2P1 at 39 weeks gestation presents to the labor and delivery triage in the second stage of labor with an overwhelming urge to push. Her pregnancy has been uncomplicated, though she missed her final prenatal visits. Bedside ultrasound confirms a frank breech presentation. Pelvic examination reveals complete cervical dilation, complete effacement, and the fetal buttocks distending the perineum at +3 station. Continuous fetal heart rate monitoring demonstrates a reassuring Category I tracing. Given the imminent delivery, the obstetrician prepares for an assisted vaginal breech delivery.

Arrange the following obstetric maneuvers and actions in the correct chronological sequence for an assisted vaginal breech delivery.

An uncomplicated full-term pregnancy brings a 29-year-old expectant mother to the obstetric triage unit experiencing painful, regular uterine contractions. Arrange the following stages and phases of a normal obstetric labor in the correct chronological order, starting from the onset of true labor and concluding with the immediate postpartum recovery period.

A healthy $25$-year-old woman, who is pregnant for the first time, visits her obstetrician for a scheduled mid-pregnancy evaluation at $26$ weeks of gestation. Her pregnancy has progressed normally without any complications, and her blood group is O positive. She states that she is feeling the baby move frequently. Her only new symptom is mild swelling in both ankles that appears in the late afternoon and resolves after resting overnight.

On physical assessment, her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $112/68 \text{ mm Hg}$, pulse is $85/\text{min}$, and respiratory rate is $14/\text{min}$. Cardiovascular auscultation reveals a soft, grade 1/6 systolic ejection murmur at the left upper sternal border. The abdomen is non-tender, and the distance from the pubic symphysis to the top of the uterus measures $26 \text{ cm}$. Trace pitting edema is noted symmetrically on the lower legs.

A panel of screening tests is performed with the following results:

Hemoglobin: $10.9 \text{ g/dL}$
Mean corpuscular volume: $89 \text{ fL}$
Leukocyte count: $11,800/\text{mm}^3$
Platelet count: $195,000/\text{mm}^3$
1-hour 50-g oral glucose challenge test: $132 \text{ mg/dL}$

Based on these findings, which of the following is the most appropriate action?

A 6-year-old girl is brought to the pediatric emergency department by emergency medical services due to a generalized tonic-clonic seizure that has been ongoing for 10 minutes. She has a known history of generalized epilepsy and recently had a gastrointestinal illness with frequent vomiting. On arrival, her eyes are deviated upward, and she has rhythmic jerking of all four extremities. Intravenous access is successfully established by the nursing staff. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient, assuming the seizure activity continues unabated despite each successive intervention.

Match each pediatric clinical presentation to the corresponding underlying enzyme deficiency.

Presenting to the emergency department is a 19-year-old nulliparous female who complains of worsening bilateral pelvic pain and an inability to keep food or liquids down since yesterday. She reports feeling feverish and having a yellowish vaginal discharge for the past three days. Her medical history is unremarkable, and she uses oral contraceptive pills inconsistently. She has had two new male sexual partners in the last month. Vital signs show a temperature of 38.9°C (102.0°F), pulse of 112/min, and blood pressure of 116/74 mmHg. Abdominal examination reveals guarding and rebound tenderness in the bilateral lower quadrants. Pelvic examination is notable for a friable cervix with mucopurulent exudate, and significant pain is elicited upon manipulation of the cervix. Bimanual examination demonstrates prominent bilateral adnexal tenderness without palpable masses. A transvaginal ultrasound reveals hyperemic, thickened fallopian tubes with trace pelvic free fluid. The ovaries are normal in size, no complex adnexal collections are present, and a normal appendix is visualized. Urine $\beta$-hCG is negative. Which of the following is the most appropriate initial management for this patient?

A $7$-month-old boy is brought to the pediatric emergency department due to a $24$-hour history of high fever, lethargy, and foul-smelling, explosive diarrhea. According to his parents, the patient has had severe constipation since birth, often requiring glycerin suppositories to pass stool. His first meconium was passed approximately $36$ hours after birth. On presentation, his temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse is $175/\text{min}$, respirations are $55/\text{min}$, and blood pressure is $72/45\text{ mmHg}$. Physical examination reveals a lethargic, ill-appearing infant with dry mucous membranes. The abdomen is markedly distended and tympanitic. Digital rectal examination is followed by a sudden expulsion of foul-smelling liquid stool and flatus. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ with $15\%$ bands. An abdominal radiograph demonstrates significantly dilated loops of bowel with multiple air-fluid levels, but no free air under the diaphragm. Which of the following is the most appropriate next step in management?

During routine prenatal evaluations of healthy, uncomplicated pregnancies, various clinical and laboratory findings frequently mimic pathological states. Match each isolated, normal physiologic finding to the primary underlying mechanism responsible for its presentation.

An obstetrician is reviewing the standard prenatal care schedule with a patient who has just established care at 8 weeks gestation. The patient, who is pregnant with her first child, has an unremarkable medical history and is currently asymptomatic. To properly educate the patient on what to expect throughout her uncomplicated singleton pregnancy, the physician outlines the timeline for standard maternal and fetal assessments. Arrange the following routine prenatal interventions in the correct chronological sequence from the earliest gestational age to the latest.

A 31-year-old female patient is evaluated in the outpatient setting for secondary amenorrhea. Her last menstrual period was eight months ago. Prior to this, her menses were regular, lasting 5 days and occurring every 29 days. She has no chronic medical conditions and takes no medications. Vital signs include a blood pressure of $112/72 \text{ mmHg}$, a heart rate of $74/\text{min}$, and a respiratory rate of $14/\text{min}$. Physical examination reveals a normal thyroid gland, no galactorrhea, and normal external genitalia with a well-estrogenized vaginal mucosa. Arrange the following diagnostic steps in the correct chronological sequence for evaluating this patient's condition, starting with the most immediate initial test and progressing to tests for anatomical abnormalities.

An obstetrician is called to evaluate a nulliparous patient in active labor at 39 weeks gestation. The patient, who has had an uncomplicated prenatal course, was admitted at 6 cm cervical dilation. Shortly after receiving continuous epidural analgesia for pain management, she reports feeling profoundly lightheaded, nauseous, and visually blurred. A focused assessment reveals a maternal blood pressure of 82/48 mm Hg and a heart rate of 112/min. Concurrently, the continuous fetal monitor demonstrates a sudden drop in the fetal heart rate from a baseline of 145/min to 85/min, which has now persisted for 3 minutes without recovery. The nursing staff has already turned the patient onto her left side and administered a rapid 500 mL intravenous bolus of lactated Ringer's solution. Upon reassessment 3 minutes later, the maternal blood pressure is 84/50 mm Hg and the fetal heart rate remains at 85/min.

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

A 4-month-old girl with trisomy 21 is evaluated in the pediatric clinic for poor feeding, diaphoresis during feeds, and inadequate weight gain over the past month. The mother reports that the infant has been breathing rapidly and occasionally wheezing. Temperature is 37.1°C (98.8°F), heart rate is 165/min, and respiratory rate is 65/min. Oxygen saturation is 95% on room air. Physical examination reveals a hyperactive precordium. Auscultation demonstrates a loud first heart sound (S1), a fixed and widely split second heart sound (S2), and a grade 3/6 holosystolic murmur best heard at the cardiac apex. A mid-diastolic rumble is also auscultated at the lower left sternal border. Lung auscultation reveals bilateral crackles and diffuse expiratory wheezing. The liver edge is palpable 3 cm below the right costal margin. Which of the following is the most likely underlying cause of this patient's current symptoms?

A 5-month-old girl is brought to the pediatric clinic by her parents due to noisy breathing that has been present since she was 2 months old. The parents report that she frequently makes a harsh, grating sound when breathing, which seems to worsen when she is crying or feeding. They have also noticed that she often tilts her head backward, which appears to ease her breathing. Over the past month, she has had episodes of choking and regurgitation during feedings, leading to poor weight gain. She has no history of fever, rhinorrhea, or cough. Two weeks ago, she was diagnosed with suspected reactive airway disease at an urgent care center and was prescribed an albuterol inhaler, which has provided no relief. Her current weight is at the 10th percentile for her age. Physical examination reveals an alert infant with biphasic stridor and mild subcostal retractions.

Which of the following is the most appropriate next step to establish the diagnosis in this patient?