All practice questions

A $31$-year-old male landscape architect seeks medical evaluation at a walk-in clinic in Rhode Island during mid-July. He describes a five-day history of low-grade fevers, profound fatigue, and a spreading skin lesion on his back. Yesterday, he began experiencing difficulty holding liquids in his mouth and noticed an inability to completely shut his right eye. Vital signs are temperature $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure $122/78\text{ mmHg}$, pulse $74/\text{min}$, and respiratory rate $14/\text{min}$. Physical examination reveals a $12\text{ cm}$ annular, erythematous plaque with a distinct zone of central clearing on the right subscapular region. Neurologic examination demonstrates drooping of the right corner of the mouth, flattening of the right nasolabial fold, and an inability to close the right eyelid. Sensation to light touch on the face is intact. There is no nuchal rigidity, and the remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?

A 6-year-old girl is diagnosed with acute lymphoblastic leukemia. Her pediatric oncologist recommends a standard chemotherapy regimen, which carries an 85% chance of complete cure. Without treatment, the condition is expected to be fatal within months. The patient's parents refuse the chemotherapy, stating they strongly prefer to treat her exclusively with holistic herbal remedies. The clinical situation is serious but does not require emergent intervention today. Arrange the following physician actions in the most appropriate chronological sequence to ethically and legally manage this parental refusal of care.

A 45-year-old man is brought to the emergency department via ambulance after falling approximately 20 feet from a roof. Upon arrival, he is moaning in pain and appears confused. His temperature is 36.1°C (97.0°F), blood pressure is 78/40 mmHg, pulse is 135/min, and respirations are 26/min. The airway is patent, and breath sounds are equal bilaterally. Physical examination reveals severe ecchymosis over the lower abdomen and perineum. The pelvis is mechanically unstable to gentle anteroposterior compression. The right lower extremity is shortened and externally rotated. A focused assessment with sonography for trauma (FAST) examination reveals no intraperitoneal or pericardial fluid. An anteroposterior radiograph of the pelvis demonstrates a 4-cm diastasis of the pubic symphysis and widening of the right sacroiliac joint. A pelvic binder is immediately applied, and a massive transfusion protocol is initiated. After receiving 2 units of uncrossmatched packed red blood cells and 1 unit of fresh frozen plasma, his blood pressure remains 80/42 mmHg and pulse is 130/min. Which of the following is the most appropriate next step in management?

A 62-year-old G3P3 postmenopausal woman presents to the urogynecology clinic with a sensation of vaginal fullness and progressive difficulty with bowel movements over the past year. She reports needing to press her fingers against the posterior wall of her vagina to successfully defecate. She desires a comprehensive plan to address her symptoms and asks about the standard protocol. Arrange the following evaluation and management steps for this patient in the standard clinical sequence, proceeding from the initial diagnostic assessment to the most invasive definitive treatment.

Emergency medical services arrive at the pediatric resuscitation bay with a $7$-year-old girl who has become progressively unresponsive over the past $12$ hours. Her caregivers describe a $3$-week prodrome of early morning cephalgia and forceful emesis. Just prior to EMS arrival, she experienced a self-resolving, $2$-minute episode of generalized body stiffening and jerking.

Initial vital signs demonstrate a temperature of $37.2^\circ\text{C}$, a heart rate of $54\text{/min}$, a blood pressure of $148/96\text{ mmHg}$, and respirations of $10\text{/min}$ with apneic pauses.

Neurologic evaluation reveals a comatose patient who does not open her eyes or vocalize, but withdraws her left arm and leg in response to nailbed pressure. The right pupil measures $7\text{ mm}$ and is fixed, whereas the left pupil measures $3\text{ mm}$ and reacts briskly to light. Deep tendon reflexes are $3+$ on the left side, and a left-sided extensor plantar response is noted.

Arrange the following interventions in the most appropriate chronological sequence for the acute management of this patient's condition.

A $7$-year-old boy is brought to the clinic by his parents due to a $2$-month history of bedwetting. He had been completely toilet trained during the day and night since the age of $4$. His parents note that he now frequently asks to use the bathroom during school and constantly craves cold water. The patient has no history of head trauma or recent illnesses. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $95/60 \text{ mm Hg}$, and pulse is $98\text{/min}$. Physical examination is unremarkable, and his growth is tracking along the $50^{\text{th}}$ percentile for both height and weight.

Initial laboratory results are as follows:

A formal water deprivation test is performed. After $6$ hours, his urine osmolality remains low at $120 \text{ mOsm/kg H}_2\text{O}$, and his serum sodium rises to $152 \text{ mEq/L}$. Subcutaneous desmopressin is then administered. Two hours later, his urine osmolality increases to $580 \text{ mOsm/kg H}_2\text{O}$.

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

An 18-month-old boy is evaluated in the pediatric clinic for progressive bowing of his legs and a waddling gait. The parents note that he began walking independently at 14 months of age, but his leg bowing has worsened since then. He was exclusively breastfed until 6 months, after which appropriate solid foods were introduced. He receives daily multivitamin drops containing 400 IU of cholecalciferol. His height is at the 3rd percentile, and his weight is at the 25th percentile. Physical examination reveals frontal bossing, widening of the wrists, and pronounced genu varum. Laboratory studies show:

Which of the following is the most likely underlying pathophysiology of this patient's condition?

An 18-month-old girl is brought to the pediatric neurology clinic by her parents due to ongoing concerns about her development and a recent "shaking episode." Yesterday, the child experienced a 1-minute generalized tonic-clonic seizure that resolved spontaneously. The parents report that over the past 4 months, the patient has completely stopped speaking the few words she knew (e.g., "mama," "dada") and no longer attempts to feed herself. Instead, she spends most of her day repetitively wringing and clasping her hands. Her past medical history is notable for normal development until 12 months of age. Additionally, she has had clear rhinorrhea for the past 2 days. On examination, the patient's temperature is 37.1°C (98.8°F), heart rate is 108/min, and respiratory rate is 22/min. The lungs are clear to auscultation bilaterally. Neurologic examination reveals a wide-based, unsteady gait and an absent pincer grasp. Review of her pediatric growth chart demonstrates that her head circumference has dropped from the 50th percentile at age 12 months to the 5th percentile currently, whereas her length and weight have remained on the 50th percentile curves. Which of the following is the most appropriate next step in the management of this patient?

A 4-month-old boy is brought to the emergency department due to poor feeding and a weak cry for the past 3 days. The parents report that he has been progressively less active and has not had a bowel movement in 5 days. He was previously healthy and exclusively breastfed, though the parents recently began dipping his pacifier in honey to soothe him. He was born at full term and his newborn screen was normal. His temperature is $37.1^\circ C$ ($98.8^\circ F$), heart rate is $140/\text{min}$, and respiratory rate is $35/\text{min}$. On physical examination, the infant appears listless. He has bilateral ptosis, sluggish pupillary responses to light, and an absent gag reflex. There is marked head lag and generalized hypotonia. The abdomen is soft and non-distended with hypoactive bowel sounds. Laboratory testing shows a thyroid-stimulating hormone (TSH) level of $2.4 \mu\text{U/mL}$ (normal: $0.5-5.0 \mu\text{U/mL}$). Which of the following is the most appropriate next step in management for this patient?

A 7-year-old boy is brought to the pediatric orthopedics clinic by his parents due to a persistent limp favoring his left leg. The parents report that the limping began approximately 5 weeks ago and is particularly noticeable after he plays outside. He occasionally complains of a dull ache in his left anterior thigh, but he denies any knee or back pain. There is no history of recent trauma, falls, or upper respiratory tract infections. His temperature is 37.0°C (98.6°F), blood pressure is 98/62 mm Hg, and pulse is 84/min. On physical examination, the patient has an antalgic gait. The left hip demonstrates restricted internal rotation and limited abduction compared to the right hip. The circumference of the left thigh is 2 cm smaller than that of the right thigh. Laboratory evaluation reveals a leukocyte count of 6,800/mm³, an erythrocyte sedimentation rate of 9 mm/hr, and a C-reactive protein level of 0.3 mg/dL. Anteroposterior and frog-leg lateral radiographs of the pelvis show completely normal bony architecture, symmetric joint spaces, and no epiphyseal flattening. Which of the following is the most appropriate next step in the diagnostic workup or management of this patient?

During a routine health maintenance visit, a physician evaluates a 2-year-old girl due to parental concerns regarding significant behavioral changes. The parents state that she achieved all early developmental milestones appropriately, including sitting unassisted at 6 months and saying single words at 12 months. However, over the past 8 months, she has lost her vocabulary and no longer makes purposeful reaching movements with her hands. Instead, she continuously claps and wrings her hands together. The parents also report intermittent episodes where she breathes very rapidly and forcefully, occasionally leading to mild wheezing, followed by periods of breath-holding. Physical examination reveals an alert child who avoids eye contact. Her head circumference has dropped from the 50th percentile at age 6 months to the 5th percentile currently. She exhibits no signs of acute distress and remains afebrile. Based on the most likely underlying condition, which of the following is the most appropriate next step in management or evaluation?

A 1-month-old boy is evaluated in the pediatric emergency department due to a 4-day history of progressively forceful vomiting. The parents report that he eagerly feeds but regurgitates the entire volume immediately afterward. The vomitus consists of undigested milk and does not appear green. The infant has not had a bowel movement in two days and is producing fewer wet diapers. Vital signs show a heart rate of $170/\text{min}$, respiratory rate of $35/\text{min}$, and blood pressure of $75/45 \text{ mm Hg}$. Physical examination reveals a lethargic infant with a sunken anterior fontanelle, dry mucous membranes, and delayed capillary refill. Palpation of the abdomen reveals a $2\text{-cm}$, firm, mobile mass in the right epigastrium. Laboratory studies reveal a pH of $7.52$, serum sodium of $132 \text{ mEq/L}$, potassium of $2.9 \text{ mEq/L}$, and chloride of $88 \text{ mEq/L}$. What is the most appropriate next step in the management of this patient?

A 30-year-old female presents to the outpatient clinic reporting the cessation of her menstrual cycles over the last 7 months. She previously experienced predictable 28-day intervals. Recently, she has been troubled by nighttime awakenings associated with intense sweating and flushing. She is sexually active with a single male partner and relies on barrier contraception. Medical history is noncontributory, and she takes no daily medications. Her body mass index is 22 kg/m $^2$. Vital signs are temperature 37.0°C (98.6°F), blood pressure 112/74 mm Hg, pulse 76/min, and respirations 14/min. Pelvic examination demonstrates pale, thinned vaginal epithelium with minimal secretions. The uterus is normal in size and non-tender, with no adnexal masses appreciated. A point-of-care urine pregnancy test is negative.

Arrange the following diagnostic and management steps in the most appropriate clinical sequence to evaluate and treat this patient's condition.

An evaluation is requested for a 68-year-old man who has developed severe anxiety, worsening palpitations, and a $4.5\text{-kg}$ ($10\text{-lb}$) unintentional weight loss over the past four weeks. He has a complex cardiovascular history including ischemic cardiomyopathy and recurrent ventricular tachycardia, which is currently managed with metoprolol, lisinopril, aspirin, and amiodarone. The amiodarone was initiated two years ago. Vital signs show a pulse of $112\text{/min}$ with an irregular rhythm, and blood pressure is $138/82\text{ mmHg}$. Physical examination reveals hyperreflexia, warm and moist skin, and a bilateral fine hand tremor. A non-tender, symmetrically enlarged thyroid gland is appreciated on palpation.

Recent laboratory results are as follows:

Which of the following is the most appropriate next step in the evaluation of this patient's current condition?

A 71-year-old man is transported to the emergency department from a local nursing facility due to the sudden onset of severe breathlessness and orthopnea that started 3 hours ago. He has a past medical history of severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$.

Upon arrival, he is visibly agitated and using accessory muscles of respiration. Vital signs are:
- Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
- Blood pressure: $172/100\text{ mm Hg}$
- Heart rate: $118\text{/min}$ and regular
- Respiratory rate: $29\text{/min}$
- Oxygen saturation: $82\%$ on ambient air

Physical examination reveals jugular venous distention when sitting upright at 45 degrees. Chest auscultation demonstrates widespread expiratory wheezing mixed with fine bibasilar crackles. Cardiac auscultation reveals tachycardia and a prominent third heart sound (S3). There is 2+ bilateral pitting edema up to the knees.

Arterial blood gas analysis on ambient air shows:
- pH: 7.22
- $PaCO_2$: $75\text{ mm Hg}$
- $PaO_2$: $48\text{ mm Hg}$
- $HCO_3^-$: $31\text{ mEq/L}$

Which of the following are the most appropriate initial steps in the management of this patient? (Select exactly two)

A 64-year-old man is evaluated in the intensive care unit for a persistent fever. He was admitted 8 days ago after a severe motor vehicle collision that resulted in multiple rib fractures, a pulmonary contusion, and a splenectomy. He has been mechanically ventilated since admission. Three days ago, he developed a temperature of 38.9°C (102.0°F), increased purulent endotracheal secretions, and increased oxygen requirements. A chest radiograph revealed a new right lower lobe consolidation. He was empirically started on intravenous cefepime, vancomycin, and amikacin. Today, his temperature is 37.4°C (99.3°F), and his oxygen requirements have decreased. The endotracheal aspirate culture from three days ago has grown Pseudomonas aeruginosa (>100,000 CFU/mL). Susceptibility testing shows the isolate is susceptible to cefepime, meropenem, piperacillin-tazobactam, and amikacin, but resistant to ciprofloxacin. No other organisms, including Staphylococcus aureus, have grown. Blood cultures obtained prior to antibiotic initiation are negative. Which of the following is the most appropriate next step in this patient's pharmacotherapy?

A primary care physician is reviewing developmental screening profiles for several pediatric patients. Match each patient's clinical presentation with the most appropriate interpretation and next step in management.

A $38$-year-old woman is brought to the emergency department by her husband due to sudden-onset confusion, agitation, and strange behavior that began this morning. For the past $3$ days, she has complained of profound fatigue, generalized weakness, and subjective fevers. She has no significant past medical history and takes no medications. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $112\text{/min}$, blood pressure is $142/88\text{ mmHg}$, and respiratory rate is $18\text{/min}$. Physical examination reveals a confused and agitated woman. There are numerous non-blanching, pinpoint erythematous macules on her bilateral lower extremities. Neurological examination reveals no focal motor or sensory deficits, but she is oriented only to person.

Laboratory studies reveal:
Hemoglobin: $7.4\text{ g/dL}$
Platelet count: $22,000/\mu\text{L}$
Leukocyte count: $9,200/\mu\text{L}$
Creatinine: $2.2\text{ mg/dL}$
Total bilirubin: $3.8\text{ mg/dL}$
Indirect bilirubin: $3.1\text{ mg/dL}$
Thyroid-stimulating hormone (TSH): $4.8\text{ }\mu\text{U/mL}$ (Normal: $0.4-4.0\text{ }\mu\text{U/mL}$)

A peripheral blood smear demonstrates numerous fragmented red blood cells.

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

Parents bring their 15-month-old son to a new pediatric clinic for a health maintenance examination. The family recently relocated from another state, which caused them to miss the child's standard 12-month evaluation. A review of his electronic medical record confirms he received all age-appropriate immunizations through his 6-month well-child visit. At 13 months of age, he experienced a generalized tonic-clonic convulsion lasting 2 minutes during an episode of high fever associated with roseola infantum. His 4-year-old sister also had a history of seizures with high fevers as an infant. Currently, the boy is healthy and takes no daily medications. Developmentally, he walks independently, stoops to pick up objects without losing his balance, points to items he wants, and uses three specific words consistently in addition to "mama" and "dada". Vital signs and physical examination are unremarkable. The physician is preparing to order catch-up vaccines, including those for measles, mumps, rubella (MMR), varicella, and seasonal influenza.

Which of the following is the most appropriate approach to this patient's preventive care today?

A 12-month-old girl is brought to the pediatric clinic for a routine health maintenance evaluation. She was born at 39 weeks of gestation via spontaneous vaginal delivery to a mother with poorly controlled HIV infection, and the patient was subsequently diagnosed with perinatal HIV at age 2 months. The patient is currently asymptomatic and her mother reports strict adherence to the prescribed antiretroviral therapy. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate 110/min, respiratory rate 24/min, and blood pressure 85/55 mm Hg. Physical examination reveals an active, well-nourished child with normal growth parameters and no lymphadenopathy or hepatosplenomegaly. Laboratory studies from two weeks ago demonstrate a CD4+ T-lymphocyte count of $1,250/\text{mm}^3$ and a CD4 percentage of $28\%$. Her immunizations are up to date and have consisted entirely of age-appropriate inactivated vaccines. The mother asks whether her daughter can receive the measles, mumps, and rubella (MMR) and varicella vaccines today. Which of the following is the most appropriate action?