All practice questions

Seeking to establish obstetric care, a patient at $10$ weeks gestation based on her last menstrual period presents to the clinic. Over the past three weeks, she has experienced progressive nausea, mild heat intolerance, and intermittent episodes where she feels her heart racing. She has no significant past medical history and takes only a daily prenatal vitamin. Vital signs demonstrate a blood pressure of $108/65$ mm Hg and a regular pulse of $98$/min. Physical examination reveals warm, moist skin. The neck examination shows a diffusely full, symmetrical thyroid gland without distinct nodules, bruit, or cervical lymphadenopathy. Eye examination is negative for proptosis or lid lag.

Initial serum laboratory investigations demonstrate the following:

Based on these findings, which of the following is the most appropriate next step in management?

A 29-year-old woman is brought to the emergency department due to a 2-week history of worsening shortness of breath, cough, and two episodes of coughing up blood. She also reports ongoing, irregular vaginal spotting for the past month. Six months ago, she had an uncomplicated spontaneous vaginal delivery of a healthy term infant. She has no significant past medical history and takes no medications. Her temperature is 37.2°C (99.0°F), blood pressure is 110/70 mm Hg, pulse is 112/min, and respiratory rate is 22/min. Pulse oximetry shows 94% on room air. Lung auscultation reveals bilateral crackles. Pelvic examination demonstrates a symmetrically enlarged, soft uterus and a 2-cm, dark red, highly vascular-appearing nodule on the posterior vaginal fornix. Chest radiography displays multiple bilateral, rounded pulmonary nodules. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

An $11$-month-old male infant is brought to the pediatric hematology clinic for a follow-up evaluation of thrombocytopenia. He has a history of recurrent acute otitis media and a recent hospitalization for pneumococcal pneumonia. His mother reports that he has been pulling himself to a stand and cruising along furniture for the past month. Physical examination reveals scattered petechiae over the lower extremities and intensely pruritic, erythematous, scaly plaques in the flexural creases of his arms and legs. Laboratory evaluation shows:

- Hemoglobin: $10.5 \text{ g/dL}$
- White blood cell count: $6,800/\text{mm}^3$ (Normal differential)
- Platelet count: $28,000/\text{mm}^3$
- Mean platelet volume (MPV): $5.5 \text{ fL}$ (Reference range: $7.5 - 11.5 \text{ fL}$)

A genetic test confirms a mutation in a gene responsible for actin cytoskeleton reorganization. Which of the following is the most appropriate management for this patient?

A medical student is reviewing pediatric chest radiographs in the neonatal intensive care unit and outpatient cardiology clinic. Pair the following congenital cardiac anomalies with their classic, historically described radiographic appearances.

During a labor induction for preeclampsia with severe features, a patient at $38$ weeks and $2$ days gestation begins experiencing acute, severe shortness of breath and a cough producing pink-tinged sputum. The patient, who is $18$ years old and nulliparous, has been receiving continuous intravenous infusions of magnesium sulfate and oxytocin for the past eight hours. Her medical history is otherwise unremarkable, and she has not received regional anesthesia. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $152/96\text{ mmHg}$, pulse of $118\text{ /min}$, and respirations of $28\text{ /min}$. Pulse oximetry indicates an oxygen saturation of $88\%$ on room air. Physical examination reveals $3+$ pitting edema of the lower extremities and bilaterally hyperactive ($3+$) patellar reflexes. Auscultation of the lungs reveals diffuse bilateral crackles extending to the apices. Pelvic examination indicates the cervix is $4\text{ cm}$ dilated and $80\%$ effaced. Fetal heart rate monitoring demonstrates a baseline of $140\text{ /min}$, moderate variability, and occasional variable decelerations that recover rapidly to baseline. Which of the following is the most appropriate next step in management?

Routine evaluation of a patient at $11$ weeks gestation is notable for her reporting a sensation of "not getting enough air." She has no history of asthma or cardiac disease, and her pregnancy has been uncomplicated. Current vital signs include a blood pressure of $112/70$ mm Hg, a pulse of $88$/min, and a respiratory rate of $18$/min. Pulse oximetry shows $99\%$ on room air. Auscultation of the chest reveals clear breath sounds bilaterally with no wheezes or crackles. Which of the following arterial blood gas profiles is most consistent with the expected physiologic adaptations in this patient?

Match each intrapartum clinical scenario and continuous fetal heart rate (FHR) tracing description to its corresponding diagnosis and underlying pathophysiology.

A 23-year-old nulligravid woman is evaluated in the emergency department for a 3-day history of progressively worsening lower abdominal pain, fever, and a malodorous vaginal discharge. Her temperature is 38.9°C (102.0°F), blood pressure is 110/70 mm Hg, and pulse is 112/min. Physical examination reveals exquisite cervical motion tenderness and a palpable, tender 6-cm fullness in the left adnexa. A urine pregnancy test is negative.

Arrange the following steps in the most appropriate chronological sequence for the optimal diagnosis and management of this patient's condition.

A pediatric oncology clinic evaluates four children and adolescents with newly diagnosed malignancies. Based on their clinical presentation and initial diagnostic findings, match each patient to the most characteristic underlying genetic or molecular abnormality.

A 28-year-old nulliparous woman presents to the gynecologist complaining of an absence of menses for the past seven months. Her menarche occurred at age 13, and her menstrual cycles were previously regular, occurring every 28 days. Eight months ago, she underwent a dilation and curettage for an incomplete spontaneous abortion. She reports no hot flashes, headaches, visual changes, or galactorrhea. Her body mass index is $22 \text{ kg/m}^2$. Pelvic examination is unremarkable. Arrange the following diagnostic and management steps in the most appropriate sequential order for evaluating this patient's secondary amenorrhea.

A 45-year-old woman, gravida 3, para 3, presents to the clinic to discuss the results of her recent routine cervical cancer screening. Her Pap smear results are reported as "Atypical Glandular Cells, favor neoplastic" (AGC-neoplastic). She is asymptomatic, has regular 28-day menstrual cycles, and her pelvic examination is unremarkable. She underwent a bilateral tubal ligation 10 years ago and does not desire future fertility. Throughout the course of her care, subsequent evaluations confirm a final diagnosis of cervical adenocarcinoma in situ (AIS) with no evidence of invasive cancer. Arrange the following clinical interventions in the standard chronological sequence for the complete evaluation and definitive management of this patient.

A 28-year-old woman, gravida 1, para 0, at 36 weeks gestation presents for a routine prenatal visit. The pregnancy has been uncomplicated. To systematically determine the fetal lie, presentation, position, and engagement, the physician performs Leopold maneuvers. Arrange the distinct steps of the Leopold maneuvers in their standard sequential order, from the first maneuver to the fourth maneuver, as performed during an obstetric examination.

A 46-year-old G2P2 woman presents to the clinic with a 5-month history of heavy, irregular vaginal bleeding. She reports her menstrual periods occur unpredictably every 18 to 40 days, lasting up to 10 days, with the passage of large clots. She has a history of type 2 diabetes mellitus and hypertension. Her body mass index is $34 \text{ kg/m}^2$. Vital signs are stable. Pelvic examination reveals a normal-appearing cervix and a bulky, mobile uterus. Arrange the following steps in the most appropriate chronological order for the evaluation and management of this patient's abnormal uterine bleeding, assuming benign initial findings and a desire to avoid surgery if possible.

Match each pediatric gastrointestinal clinical presentation (left) with its most characteristic imaging or histopathologic diagnostic finding (right).

A 4-year-old boy is admitted to the hospital with a 7-day history of persistent fever measuring up to 39.5°C (103.1°F). Physical examination reveals bilateral bulbar conjunctival injection without exudate, brightly erythematous and cracked lips, a prominent 'strawberry' tongue, erythema and edema of the palms and soles, and a 2.5-cm right-sided cervical lymph node. A diagnosis of Kawasaki disease is made. Arrange the following therapeutic and follow-up steps in the most appropriate chronological order for the optimal management of this patient, from initial hospitalization to long-term preventive care.

A $33$-year-old woman presents to the clinic complaining of an absence of menses for the past $9$ months. Her previously regular $28$-day menstrual cycles stopped completely, although she did experience a single episode of light vaginal spotting one week ago. Over the past year, the patient has also developed profound fatigue, cold intolerance, constipation, and occasional mild morning headaches. She recently noticed a spontaneous milky discharge from both breasts. She takes no medications and has no significant past medical history. Vital signs show a blood pressure of $110/70$ mm Hg and a heart rate of $56$/min. Body mass index is $24$ kg/m $^2$. Physical examination reveals dry skin and delayed relaxation of the deep tendon reflexes. Visual fields are full to confrontation. Pelvic examination is unremarkable.

Laboratory results are as follows:

Which of the following is the most likely diagnosis?

A $2$-hour-old male neonate, born at $39$ weeks gestation to a mother with poorly controlled pregestational diabetes mellitus, is evaluated in the nursery for persistent cyanosis. The pregnancy was otherwise uncomplicated. Vital signs show a heart rate of $160$/min, respiratory rate of $65$/min, and blood pressure of $65/40$ mm Hg in the right arm and $68/42$ mm Hg in the left leg. Pulse oximetry reveals an oxygen saturation of $72\%$ on room air. Administration of $100\%$ oxygen via headbox for $15$ minutes fails to increase the oxygen saturation above $75\%$. Physical examination shows a deeply cyanotic infant with mild intercostal retractions. Cardiac auscultation reveals a normal first heart sound, a loud and single $S_2$, and no murmurs. The lungs are clear to auscultation bilaterally. Which of the following is the most appropriate next step in management?

During a scheduled prenatal visit, a gravid patient at 18 weeks gestation reports experiencing severe vulvovaginal pruritus and a new onset of profuse, malodorous vaginal discharge for the past week. She has no uterine contractions, leakage of fluid, or vaginal bleeding. Her prenatal course has been uncomplicated thus far. On pelvic examination, the vaginal mucosa is erythematous, and a frothy, yellow-green discharge is pooled in the posterior fornix. The cervix appears inflamed with prominent punctate hemorrhages. Vaginal fluid pH testing yields a result of 6.0. Microscopic evaluation of a saline wet preparation reveals numerous polymorphonuclear leukocytes and pear-shaped, motile protozoa. Which of the following is the most appropriate management for this patient?

An on-call physician evaluates a 22-month-old girl in the pediatric emergency triage area due to a sudden onset of respiratory distress. Her parents state that she was previously healthy and had been eating mixed nuts with her older brother in the living room when she suddenly began having a severe coughing fit. She has no history of fever, rhinorrhea, or recent ill contacts. Her temperature is 37.1°C (98.8°F), heart rate is 142/min, respiratory rate is 44/min, and oxygen saturation is 92% on room air. Physical examination reveals a visibly anxious toddler with suprasternal retractions. Auscultation demonstrates significantly diminished breath sounds and high-pitched wheezing isolated to the right hemithorax. An upright expiratory chest radiograph shows right-sided hyperinflation and a leftward shift of the mediastinum. Which of the following is the most appropriate next step in the management of this patient?

A 61-year-old nulliparous woman comes to the physician because of vaginal bleeding for the past 2 weeks. She reached menopause 9 years ago and had not experienced any bleeding until now. Over the past month, she has also noticed new-onset bilateral breast tenderness. She has no other medical conditions and takes no medications. Her body mass index is 23 kg/m^2. Vital signs are within normal limits. Pelvic examination reveals a normal-appearing vagina and cervix. Bimanual examination palpates a 7-cm, firm, mobile right adnexal mass. Transvaginal ultrasound shows a complex right ovarian mass with both solid and cystic components, along with an endometrial thickness of 14 mm. Which of the following is the most appropriate next step in management?