All practice questions

A seven-year-old girl with a history of retroperitoneal neuroblastoma is brought to the emergency department due to severe, worsening mid-back pain for the past three days and new-onset difficulty walking over the last twelve hours. Her parents report she has not voided urine since yesterday evening. Vital signs are within normal limits for her age. Neurologic examination reveals grade three out of five motor strength in the bilateral lower extremities, hyperreflexia at the patellae, and decreased sensation to light touch below the umbilicus. The bladder is palpably distended. Arrange the following management steps in the most appropriate chronological sequence for this patient's suspected complication.

Match each patient's clinical profile with the most appropriate contraceptive method based on the World Health Organization Medical Eligibility Criteria (WHO MEC) and the patient's personal preferences.

Match each patient's clinical presentation of secondary amenorrhea with the most likely underlying pathophysiologic mechanism.

During a health maintenance visit, a $54$-year-old woman (G2P2) returns to the clinic to discuss the results of her recent cervical cancer screening. Two weeks prior, she underwent a routine Pap test and reported a self-resolving episode of brownish vaginal spotting. She reached menopause at age $50$ and does not take hormone replacement therapy. Her past medical history is notable for obesity with a body mass index of $32$ and well-controlled hypertension. The cytology report indicates atypical glandular cells (AGC), and high-risk human papillomavirus (HPV) co-testing is negative. Pelvic examination demonstrates a parous, normal-appearing cervix without visible lesions, and bimanual examination reveals a mobile, non-tender uterus of normal size. Which of the following is the most appropriate next step in the diagnostic workup for this patient?

Seeking contraceptive counseling, a 25-year-old nulligravid woman presents to the gynecology clinic. She is in a monogamous relationship and desires to prevent pregnancy for at least the next five years. Her medical history is significant for Wilson disease, which is currently well-managed with trientine. She also reports a longstanding history of heavy menstrual bleeding that has previously required intermittent oral iron supplementation for mild anemia. Her current medications include trientine and a daily multivitamin. Vital signs are within normal limits, and her body mass index is 24 kg/m $^2$. A point-of-care urine pregnancy test is negative. The patient requests a highly effective, long-acting reversible contraceptive (LARC) method. Which of the following is the most appropriate recommendation for this patient?

A 29-year-old woman, gravida 3, para 2, is evaluated on the labor and delivery unit at 38 weeks of gestation. She reports a sudden gush of clear vaginal fluid occurring 20 minutes ago, followed by the onset of strong, painful uterine contractions. Her previous deliveries were full-term, uncomplicated vaginal births. Her temperature is 37.1 C (98.8 F), blood pressure is 112/70 mm Hg, and pulse is 85/min. On pelvic examination, the cervix is 5 cm dilated and 80% effaced. The fetal presenting part is ballottable at a -3 station, and a smooth, pulsatile, rope-like mass is palpated in the vaginal vault extending through the cervical os. Simultaneously, continuous electronic fetal monitoring demonstrates an abrupt decrease in the fetal heart rate to 80/min that has lasted for the past 90 seconds. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old woman is evaluated on the maternity ward on postpartum day 2 for new-onset fever and pelvic pain. She delivered a full-term neonate via low transverse cesarean delivery following a diagnosis of active phase arrest. Her membranes were ruptured for 18 hours prior to the procedure. Over the last few hours, she has developed chills and worsening lower abdominal discomfort. Vital signs show a temperature of 39.2°C (102.6°F), blood pressure of 115/72 mm Hg, and heart rate of 110/min. Physical examination reveals clear lungs and soft, non-tender breasts. Abdominal examination demonstrates a soft abdomen with a well-approximated surgical incision that is free of erythema or induration. Deep palpation of the suprapubic region elicits marked uterine tenderness. The perineal pad contains a moderate amount of malodorous, purulent lochia. Urinalysis is unremarkable. Which of the following is the most appropriate next step in management?

A $6$-year-old boy with sickle cell disease (HbSS) is brought to the emergency department due to increasing fatigue and generalized weakness over the past $48$ hours. One week ago, he had a low-grade fever accompanied by a bright red "slapped-cheek" facial rash that has since faded. He reports no pain in his chest, abdomen, or extremities. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $95/60 \text{ mm Hg}$, pulse is $135/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals marked conjunctival pallor and a grade $2/6$ systolic flow murmur at the left upper sternal border. The abdomen is soft and non-tender, and the spleen is not palpable. Laboratory studies show:

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

Paramedics arrive at the emergency department with a 4-week-old infant who is lethargic and feverish. The infant's parents report a 12-hour history of explosive, foul-smelling diarrhea and progressive abdominal swelling. Medical history is notable for delayed meconium passage after birth, which required a glycerin suppository. Vital signs show a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), a heart rate of $185\text{/min}$, a respiratory rate of $60\text{/min}$, and a blood pressure of $58/30\text{ mm Hg}$. The capillary refill time is 4 seconds. On physical examination, the infant is poorly responsive and has a markedly distended, tense abdomen. The clinical picture is highly suspicious for Hirschsprung-associated enterocolitis complicated by septic shock.

Arrange the following management steps in the most appropriate chronological sequence for this patient's immediate care.

A 29-year-old multiparous patient at 40 weeks gestation is in the second stage of labor. Following the delivery of the fetal head, it retracts tightly against the maternal perineum ('turtle sign'). Gentle downward traction fails to deliver the anterior shoulder. Arrange the following steps in the most appropriate sequence of escalation for managing this obstetric emergency according to standard protocols.

Match each clinical vignette involving a legal or ethical dilemma in a psychiatric setting with the most appropriate next step in management or mandated action.

A 45-year-old woman is brought to the emergency department after being thrown from a horse. She was wearing a helmet but landed forcefully on her back. Upon arrival, she is immobilized on a rigid backboard with a cervical collar. She is conscious and alert but reports an inability to move her legs and a lack of sensation below her chest. Vital signs reveal a blood pressure of $78/42$ mmHg, a heart rate of $54$/min, and a respiratory rate of $16$/min. Oxygen saturation is $98\%$ on room air. Physical examination demonstrates warm, flushed skin in the upper and lower extremities. Pulses are bounding. Which of the following is the most likely etiology of this patient's hemodynamic findings?

A 25-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He is unresponsive and has sustained multiple injuries. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial management steps of the primary survey in the correct chronological order.

Match each patient's clinical presentation with the most likely corresponding substance intoxication or withdrawal syndrome.

An unmedicated 28-year-old male graphic designer comes to the physician seeking help for debilitating 'panic spells'. He states that over the last four months, he has suffered six unexpected episodes of overwhelming fear, pounding heart, diaphoresis, and a feeling that he might die. These episodes reach maximum intensity within a few minutes. He has become increasingly fearful of experiencing another attack and now refuses to ride the city bus to his office.

Physical examination, electrocardiography, and laboratory studies (including thyroid function) show no abnormalities.

During the clinical interview, the patient discloses a history of severe depression in his early twenties. Furthermore, at age 24, he experienced a distinct three-week period characterized by a markedly decreased need for sleep, pressured speech, and grandiose delusions that he was a famous inventor, which resulted in a psychiatric hospitalization. He has not taken any prescribed medications for the past two years.

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

Match each clinical presentation to the most accurate sleep-wake disorder diagnosis.

Match each pharmacotherapy used in the treatment of substance-related and addictive disorders to its primary mechanism of action, key clinical consideration, or contraindication.

A psychiatry care team is reviewing the management plans for four distinct patients presenting with psychotic spectrum symptoms. Match each patient's specific clinical scenario to the most appropriate next step in pharmacological management.

Match the following classic patterns of abdominal pain to the most likely acute intra-abdominal diagnosis.

A 37-year-old man comes to the psychiatrist complaining of feeling "completely empty" for the past 2 months. He reports that he has lost interest in his architectural work, which he usually loves, and struggles to get out of bed before noon. His appetite has decreased, leading to an 8-lb (3.6-kg) weight loss. He expresses intense guilt over a minor calculation mistake he made on a project a year ago. A review of his past medical records reveals an emergency department visit 3 years ago for acute agitation. During that visit, he was speaking so quickly he was difficult to understand, claimed he had discovered the secret to limitless energy, and had not slept in 5 days. He was stabilized on a medication that he subsequently stopped taking because he felt it blunted his creativity. His vital signs and physical examination today are unremarkable. Which of the following is the most appropriate next step in the pharmacologic management of this patient's current symptoms?