All practice questions

A 22-year-old male is evaluated in the surgical intensive care unit for sudden-onset, severe abdominal pain. Three days ago, he was involved in a high-speed motorcycle collision, during which he was thrown forward and struck his upper abdomen against the handlebars. His initial trauma evaluation in the emergency department demonstrated stable hemodynamics, and a computed tomography scan of the abdomen and pelvis showed a non-expanding Grade II splenic laceration without active contrast extravasation. He was admitted for nonoperative management and had been clinically stable until this morning.

Current vital signs include a temperature of 38.6°C (101.5°F), a heart rate of 135/min, a respiratory rate of 24/min, and a blood pressure of 82/48 mm Hg. Physical examination reveals a distended abdomen with diffuse rigidity, involuntary guarding, and severe rebound tenderness in all four quadrants. Bowel sounds are absent. Following the rapid infusion of 2 L of isotonic crystalloid, his blood pressure remains 86/50 mm Hg.

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

During a routine health maintenance visit, the parents of a 5-year-old child express concern about multiple dark spots that have appeared on the child's skin over the past few years. The parents state that the child has generally been healthy. The father notes he was briefly worried when the child began walking independently at 14 months of age, but the child now runs, climbs stairs, and speaks in complete sentences. Vital signs are within normal limits for age. Physical examination reveals seven flat, uniformly hyperpigmented, oval macules measuring 10 to 15 mm in diameter scattered across the thorax and back. Distinct clusters of small freckles are also observed in the axillary and inguinal regions. The remainder of the physical and neurological examination is unremarkable. Based on the most likely diagnosis, which of the following are appropriate components of this patient's ongoing management? (Select 2)

A $3$-week-old female infant is rushed to the emergency department by her parents after she began forcefully vomiting green-tinged fluid earlier in the day. She has vomited several times and has become increasingly lethargic over the past few hours. Her parents note that she had a normal bowel movement yesterday. The pregnancy was uncomplicated, and she was born at full term.

Vital signs reveal a heart rate of $185$/min, respiratory rate of $60$/min, and blood pressure of $62/34$ mm Hg. Her temperature is $37.9^\circ$ C ($100.2^\circ$ F). On physical examination, the infant appears pale and poorly responsive. Capillary refill time is $5$ seconds. Abdominal evaluation shows marked distension, absent bowel sounds, and involuntary guarding with rigidity when palpated. Additionally, there are scattered erythematous macules with central tiny yellow pustules on her anterior trunk.

Laboratory results are as follows:

Arterial blood gas:
pH: $7.21$
pCO $_2$: $32$ mm Hg
HCO $_3^-$: $12$ mEq/L

Serum lactate: $6.8$ mmol/L (Normal: $0.5$ - $2.2$ mmol/L)

A plain radiograph of the abdomen displays a few dilated loops of small intestine without any gas in the distal bowel. There is no evidence of free intraperitoneal air.

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

A 1-day-old male neonate is evaluated in the nursery for persistent central cyanosis. He was born at 39 weeks gestation via uncomplicated vaginal delivery to a 28-year-old primigravida. His mother had limited prenatal care but reports taking no medications during pregnancy. On examination, the infant appears comfortable but is notably cyanotic. Vital signs show a heart rate of 155/min, respiratory rate of 55/min, and oxygen saturation of 74% on room air. The cyanosis does not improve with the administration of 100% oxygen via hood. Cardiovascular examination reveals a loud, single second heart sound (S2) and a grade 3/6 holosystolic murmur at the left lower sternal border. Lungs are clear to auscultation. An electrocardiogram (ECG) demonstrates left axis deviation and tall, peaked P waves, with absent R waves in the right precordial leads. Chest radiography shows decreased pulmonary vascular markings and a normal heart size. Which of the following is the most likely diagnosis?

A 39-year-old nulligravid female presents to the physician reporting eight months of heavy, unpredictable vaginal bleeding. Her menstrual cycles were previously regular, occurring every $28$ to $30$ days and lasting $5$ days. Over the past eight months, bleeding episodes have occurred at irregular intervals ranging from $15$ to $45$ days, with menses lasting up to $10$ days and requiring her to change super-absorbency pads every two hours on heavy days. Medical history is significant for type 2 diabetes mellitus, chronic hypertension, and morbid obesity. Current medications include metformin and lisinopril. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $148/92\text{ mm Hg}$, pulse of $82/\text{min}$, and a body mass index (BMI) of $42\text{ kg/m}^2$. Pelvic examination reveals normal external genitalia, a normal-appearing cervix, and a bulky but non-tender uterus. A urine pregnancy test is negative. Laboratory studies show a hemoglobin level of $10.2\text{ g/dL}$. Which of the following is the most appropriate next step in the management of this patient?

An established $34$-year-old patient presents to the gynecology clinic reporting relentless vulvovaginal pruritus and burning that has persisted for the past month. She states that a three-dose course of oral fluconazole prescribed four weeks ago provided almost no symptom relief. Her past medical history is notable for poorly controlled type 2 diabetes mellitus with a recent hemoglobin A1c of $9.2\%$. On speculum examination, the vulvar and vaginal mucosae are intensely erythematous, and there is a thick, white, clumpy discharge adherent to the vaginal sidewalls. Vaginal fluid pH is $4.2$. Microscopic evaluation of the discharge prepared with $10\%$ potassium hydroxide reveals numerous budding yeast cells, but a complete absence of pseudohyphae or true hyphae. Which of the following is the most appropriate pharmacotherapy for this patient's condition?

A 29-year-old G1P0 at 39 weeks gestation undergoes an emergent cesarean delivery. She presented to the labor triage unit 20 minutes prior with painful uterine contractions and a history of a sudden gush of fluid at home. Upon admission, her cervix was 6 cm dilated, and the fetal heart rate was found to be persistently in the 60s, prompting immediate surgical intervention. A male neonate is delivered and requires positive pressure ventilation.

Umbilical artery blood gas analysis is obtained immediately after delivery:

Which of the following is the most likely primary mechanism for this neonate's acid-base derangement?

A 30-year-old nulliparous woman presents to the clinic for preconception counseling. She plans to discontinue her oral contraceptives and attempt pregnancy in the coming months. The patient is highly detail-oriented and requests a comprehensive timeline of the routine medical evaluations she should expect once she conceives. The physician explains the standard sequence of prenatal care milestones. Assuming she achieves an uncomplicated, spontaneous singleton pregnancy and establishes care early in the first trimester, arrange the following routine prenatal screening evaluations in the correct chronological order from earliest to latest in gestation.

A 15-month-old toddler is evaluated in the outpatient clinic during mid-winter with a four-day history of low-grade fever, rhinorrhea, and worsening cough. His mother notes that he has been breathing faster than usual today and has been feeding slightly less, though he continues to produce wet diapers. The patient's past medical history is significant for atopic dermatitis, and both parents have a history of moderate persistent asthma. His temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), pulse is $148/\text{min}$, respirations are $58/\text{min}$, and pulse oximetry reveals an oxygen saturation of $95\%$ on room air. Physical examination shows an interactive child with mild intercostal retractions and copious nasal secretions. Auscultation of the lungs reveals a prolonged expiratory phase with widespread, high-pitched wheezing and bilateral coarse crackles. Which of the following is the most appropriate next step in the management of this patient?

A $29$-year-old woman, G1P1, is evaluated on postpartum day $3$ for a new-onset fever, chills, and lower abdominal pain. Three days ago, she underwent a primary low transverse cesarean delivery due to active phase arrest. Her membranes had been ruptured for $22$ hours prior to delivery. Her temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure is $112/72\text{ mmHg}$, pulse is $112/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals soft, non-tender breasts without erythema. Her abdomen is soft. The cesarean incision is clean, dry, and intact, with no erythema, induration, or purulent drainage. Palpation of the uterine fundus elicits severe tenderness. Pelvic examination reveals a normal-appearing cervix with moderate, foul-smelling lochia. Which of the following is the most appropriate next step in the management of this patient?

A 6-week-old boy is evaluated in the clinic for a worsening, repetitive cough that started one week ago. His mother reports that the cough comes in rapid, machine-gun-like bursts. The infant has not had a fever and continues to breastfeed well, although he occasionally spits up after coughing. Pregnancy and vaginal delivery were uncomplicated, though the mother received limited prenatal care. At 2 weeks of age, the infant had watery, red eyes that resolved over several days without specific treatment. Vital signs are temperature 37.0°C (98.6°F), heart rate 145/min, and respiratory rate 55/min. Pulse oximetry is 97% on room air. Physical examination reveals an alert infant. Lung auscultation demonstrates bilateral scattered crackles with no prominent wheezing. A chest radiograph shows bilateral symmetrical interstitial infiltrates and hyperinflation. Laboratory studies reveal a leukocyte count of 12,000/mm³ with 12% eosinophils. Which of the following is the most appropriate pharmacotherapy for this patient?

A 22-year-old woman presents to the outpatient clinic reporting a 5-day history of yellowish vaginal discharge and spotting after intercourse. Her last menstrual period was 6 weeks ago, and she reports inconsistent condom use with a new male partner. Her temperature is 37.2°C (99.0°F), blood pressure is 110/70 mm Hg, and pulse is 82/min. Speculum examination reveals a friable cervix with mucopurulent exudate. Bimanual examination demonstrates mild cervical motion tenderness without uterine or adnexal tenderness. Arrange the following steps in the most appropriate chronological sequence for the clinical and public health management of this patient.

A pediatric patient with a known history of severe hemophilia A is evaluated for acute-onset right knee pain and swelling. The child's caregivers administered the prescribed on-demand recombinant factor VIII concentrate twice over the preceding 24 hours; however, the joint effusion and pain have continued to worsen. He currently refuses to bear weight on the affected limb. Vital signs show a temperature of 37.1°C (98.8°F), heart rate of 110/min, and blood pressure of 100/65 mm Hg. Physical examination reveals a tense, warm, and highly tender right knee with a restricted range of motion. Laboratory evaluation demonstrates a normal prothrombin time (PT) and a significantly prolonged activated partial thromboplastin time (aPTT). An incubation mixing study is performed; the aPTT fails to correct upon the addition of normal plasma. Which of the following is the most appropriate next step in management?

A 26-year-old primigravid patient at 40 weeks gestation is admitted to the labor and delivery unit in active spontaneous labor. Her prenatal course was uncomplicated. Spontaneous rupture of membranes occurred 4 hours ago, revealing thick meconium-stained amniotic fluid. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mmHg, and pulse is 82/min.

Pelvic examination demonstrates the cervix is 6 cm dilated, 100% effaced, and the fetal vertex is at 0 station. No structures are palpable ahead of the presenting part.

Continuous external fetal monitoring over the last 30 minutes shows a baseline heart rate of 140/min and moderate variability. There are recurrent, abrupt decreases in the fetal heart rate to 80/min that last for 45 to 60 seconds before returning rapidly to baseline. These decreases do not have a consistent temporal relationship with the uterine contractions. The contractions are occurring every 3 to 4 minutes and last 60 seconds.

The nurse assists the patient into the left lateral, right lateral, and hands-and-knees positions, and administers a 500 mL intravenous bolus of lactated Ringer solution. Despite these resuscitative maneuvers, the fetal heart rate pattern remains unchanged for the next 20 minutes. A repeat cervical examination shows no change in dilation.

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

An $18$-month-old toddler is evaluated at the primary care clinic for a cough and fever. She initially developed clear rhinorrhea and a mild cough four days ago. Yesterday, her cough worsened, and she developed a fever. Her parents report that she is drinking fluids adequately but has a decreased appetite. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse is $142/\text{min}$, and respiratory rate is $48/\text{min}$. Oxygen saturation is $96\%$ on room air. Physical examination reveals a well-developed child in mild respiratory distress. Auscultation of the lungs demonstrates focal crackles and decreased breath sounds over the left lower lung field. No wheezing or stridor is appreciated. Capillary refill is less than $2$ seconds. Based on these clinical findings, what is the most appropriate initial pharmacological management?

Match each patient's clinical profile with the most appropriate contraceptive method based on the Medical Eligibility Criteria for Contraceptive Use.

A 24-year-old primigravid woman at 39 weeks gestation is evaluated in the labor and delivery unit. She was admitted 22 hours ago in active labor, at which time spontaneous rupture of membranes occurred. Her current temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and heart rate is 118/min. Physical examination reveals a diffusely tender uterine fundus. Pelvic examination shows the cervix is 6 cm dilated, 100% effaced, and the fetal vertex is at 0 station. Purulent fluid is noted in the vaginal vault. The fetal heart rate tracing demonstrates a baseline of 175/min with moderate variability and no decelerations. Maternal laboratory studies show a leukocyte count of $18,000/\text{mm}^3$ and a hemoglobin of $10.4 \text{ g/dL}$. Which of the following is the most appropriate next step in the management of this patient?

A 2-year-old girl is brought to the emergency department 30 minutes after accidentally ingesting a liquid drain cleaner containing sodium hydroxide. She is crying, drooling continuously, and refusing to swallow. Her temperature is 37.2°C (99.0°F), heart rate is 140/min, respiratory rate is 30/min, and oxygen saturation is 98% on room air. Physical examination reveals mild inspiratory stridor, swollen erythematous lips, and small ulcerations on the buccal mucosa. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 3-week-old female infant is brought to the emergency department by her parents due to poor feeding, extreme fussiness, and rapid breathing for the past 6 hours. Her vital signs are heart rate 265/min, respiratory rate 50/min, blood pressure 78/45 mm Hg, and oxygen saturation 97% on room air. Physical examination reveals a well-perfused infant with brisk capillary refill (less than 2 seconds) and normal peripheral pulses. An electrocardiogram demonstrates a regular, narrow-complex tachycardia with no discernible P waves.

Arrange the following interventions in the most appropriate sequence for managing this patient's condition, from the initial step to subsequent refractory therapies.

During a scheduled mid-trimester visit at $20$ weeks gestation, a $32$-year-old multigravida reports feeling generally well, with only mild fatigue and occasional urinary frequency. Her blood pressure is $115/75$ mmHg and pulse is $82$/min. Physical examination reveals a fundal height consistent with dates and normal fetal heart tones. Routine laboratory screening is performed with the following results:

Hemoglobin: $11.2$ g/dL
Leukocyte count: $12,500$/mm $^3$
Serum creatinine: $1.1$ mg/dL
Alkaline phosphatase: $195$ U/L
Urinalysis: Trace glucose, negative for protein and nitrites

Which of the following laboratory findings in this patient is abnormal and warrants further diagnostic evaluation?