All practice questions

A 2-year-old boy is brought to the emergency department due to refusal to walk for the past 12 hours. His parents note he was well yesterday but awoke crying and pointing to his right leg. His current temperature is $39.5^{\circ}C$ ($103.1^{\circ}F$). On examination, the child is irritable, and the right hip is held rigidly in flexion, abduction, and external rotation. Any attempt to move the joint elicits severe distress. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for managing this patient's condition.

A 9-month-old girl is brought to the emergency department due to intermittent episodes of severe crying. During these episodes, she draws her legs up to her chest and appears to be in significant pain. Between episodes, she is calm and plays with her toys. Her parents report one episode of nonbilious emesis and note that her most recent diaper contained dark red, mucus-like stool. Her vital signs are stable, and abdominal examination reveals a palpable sausage-shaped mass in the right upper quadrant without guarding or rebound tenderness. Arrange the following steps in the standard chronological order of management for this patient.

A 7-year-old boy with a history of meconium ileus in infancy presents to the pulmonary clinic for a routine follow-up. He has a chronic daily cough producing thick, purulent sputum and has required multiple hospitalizations for respiratory exacerbations. He is currently in the 10th percentile for weight and 15th percentile for height. Sweat chloride testing reveals a concentration of $95 \text{ mmol/L}$ (normal $<39 \text{ mmol/L}$). The patient's progressive pulmonary disease is driven by a well-described pathophysiologic cascade.

Arrange the following pathophysiologic events in the chronological sequence that leads to this patient's chronic lung disease, starting with the primary cellular defect.

A 2-year-old boy is brought to the pediatric emergency department with a 6-day history of high fever, bilateral non-exudative conjunctivitis, cracked red lips, and a polymorphous maculopapular rash on his trunk. Physical examination reveals cervical lymphadenopathy and erythema of the palms and soles. A clinical diagnosis of Kawasaki disease is made. Arrange the following steps in the correct chronological sequence for the standard management and follow-up of this patient.

A 14-year-old boy is evaluated in the emergency department for a 3-day history of progressively worsening headache, blurred vision, and shortness of breath. Physical examination reveals pale conjunctivae, scattered petechiae, and bilateral retinal hemorrhages. Vital signs are temperature 37.8°C (100.0°F), heart rate 132/min, respiratory rate 28/min, and blood pressure 110/65 mmHg. Pulse oximetry shows 92% on room air.

Laboratory studies show:
Leukocytes: 380,000/mm³ (90% myeloblasts)
Hemoglobin: 5.2 g/dL
Platelets: 22,000/mm³
Uric acid: 9.8 mg/dL
Potassium: 4.8 mEq/L
Creatinine: 1.1 mg/dL

Arrange the following interventions in the most appropriate chronological sequence to safely manage this patient's acute presentation.

A young patient with an intrauterine pregnancy confirmed by home testing presents for initial obstetric care. She is currently at 8 weeks gestation based on her last menstrual period. She has no chronic medical conditions. Throughout the course of a normal, low-risk pregnancy, arrange the following standard prenatal evaluations in the correct chronological sequence from earliest to latest.

A 7-year-old girl is brought to the pediatrician by her father, who recently noticed that she is developing breasts and has experienced a rapid increase in height over the past year. Vital signs are within normal limits for her age. Physical examination reveals Tanner stage 3 breast development and Tanner stage 2 pubic hair. No axillary hair or acne is noted, and the neurological examination is unremarkable. The physician suspects an early onset of puberty. Arrange the following steps in the most appropriate chronological sequence for the diagnostic evaluation and management of this patient's condition.

An infant delivered at full term is admitted to the neonatal intensive care unit at 48 hours of life due to progressive lethargy, hypotonia, and Kussmaul respirations. Initial laboratory evaluation reveals a severe high anion gap metabolic acidosis ($pH\ 7.12$, $HCO_3^{-}\ 7\ mEq/L$), hypoglycemia ($34\ mg/dL$), and moderate hyperammonemia ($420\ \mu mol/L$). The clinical presentation is highly suspicious for an acute metabolic crisis secondary to an inborn error of metabolism, such as an organic acidemia. Arrange the following acute management and diagnostic steps in the most appropriate sequential order of priority for this patient.

A term patient in active labor reaches complete cervical dilation and begins the pushing phase. After several contractions, the fetal head emerges but then abruptly retracts against the vulva, and the fetal cheeks begin to bulge. Standard gentle downward traction does not yield delivery of the body. Arrange the following interventions in the correct sequential order for managing this clinical scenario, from initial response to maneuvers of last resort.

A 2-year-old boy is brought to the emergency department after a witnessed choking episode while eating mixed nuts 1 hour ago. He had a severe fit of coughing initially, which has since subsided. On physical examination, he is alert and in mild respiratory distress. Vital signs show a temperature of 37.1°C (98.8°F), heart rate of 122/min, respiratory rate of 28/min, and oxygen saturation of 96% on room air. Lung auscultation reveals diminished breath sounds and localized expiratory wheezing over the right middle lobe. Arrange the following interventions in the most appropriate chronological sequence for the evaluation and management of this patient.

A 4-year-old boy is brought to the emergency department by his parents due to a sudden onset of high fever, severe sore throat, and difficulty breathing that started 4 hours ago. His parents state that they recently moved to the country and his childhood immunizations are incomplete. On examination, the patient appears toxic, highly anxious, and is sitting upright on his mother's lap, leaning forward with his neck hyperextended and jaw thrust forward. He is actively drooling and speaks in a muffled voice. Pronounced inspiratory stridor is audible without a stethoscope. Vital signs are temperature 39.8°C (103.6°F), heart rate 155/min, respiratory rate 42/min, and oxygen saturation 93% on room air.

Arrange the following management steps in the most appropriate sequential order for this patient.

A 29-year-old primigravida presents to the obstetrics clinic to establish prenatal care. According to a recent dating ultrasound, she is at 9 weeks gestation. She has no significant past medical history and currently takes a daily prenatal vitamin. Her blood pressure is 112/68 mm Hg, heart rate is 82/min, and body mass index is 23 kg/m $^2$. Physical examination is unremarkable. The patient is eager to understand the upcoming milestones in her pregnancy and asks the physician to explain the precise timeline of routine testing she will undergo over the next several months.

Arrange the following routine prenatal screening tests and evaluations in the chronological order they should be offered or performed during this patient's uncomplicated pregnancy.

A 2-day-old full-term neonate is evaluated in the nursery for failure to pass meconium and progressive abdominal distension. Physical examination reveals a remarkably tight anal sphincter. Upon withdrawal of the examiner's finger during a digital rectal examination, there is an explosive release of gas and foul-smelling stool. Arrange the following steps in the optimal diagnostic and therapeutic sequence for this patient's suspected condition.

A 10-year-old boy is currently admitted to the pediatric intensive care unit following a severe traumatic brain injury. He is intubated, mechanically ventilated, sedated, and has an external ventricular drain in place. Over the last five minutes, his intracranial pressure monitor indicates a sudden and sustained spike to 40 mm Hg (normal is less than 15 mm Hg). Simultaneously, his heart rate drops to 45/min, and his blood pressure rises to 160/90 mm Hg. Arrange the following acute management steps for suspected impending brain herniation in the most appropriate escalating sequence, proceeding from basic initial maneuvers to advanced refractory therapies.

A 14-month-old girl is rushed to the pediatric emergency center by her parents because she suddenly became severely cyanotic and limp after a prolonged crying episode at home. On arrival, she is highly agitated, inconsolable, and instinctively drawing her legs toward her abdomen. Vital signs show a heart rate of 178/min, respiratory rate of 52/min, and oxygen saturation of 62% on room air. Auscultation reveals a harsh, grade 3/6 systolic ejection murmur at the left mid-to-upper sternal border, which the parents note is much softer than what was described during her last pediatric visit. She is diagnosed with a hypercyanotic spell secondary to an underlying congenital heart defect. Arrange the following interventions in the most appropriate sequential order for the acute escalation of management for this patient, starting with the immediate first step and progressing to treatments for medically refractory symptoms.

A 7-year-old girl is rushed to the pediatric emergency department with continuous rhythmic jerking of her arms and legs that began 12 minutes ago while at school. She has no prior history of seizures. On arrival, she is unresponsive, her pulse oximetry reads 89% on room air, and she has active generalized tonic-clonic movements. A peripheral intravenous line is rapidly established by the nursing staff. Arrange the following management steps in the correct chronological sequence for the optimal acute algorithmic management of this patient's condition, from immediate priority to late-stage refractory care.

A 28-year-old G2P1 presents to the clinic to establish prenatal care. She has a history of irregular menstrual cycles and is unsure of her last menstrual period. She will undergo serial transvaginal and transabdominal obstetric ultrasounds to confirm intrauterine pregnancy, verify gestational age, and assess early fetal development. Arrange the following normal sonographic landmarks in the typical chronological order of their initial appearance during a developing intrauterine pregnancy, from earliest to latest.

A full-term female infant is delivered vaginally from a breech presentation. The mother has a positive family history of developmental dysplasia of the hip (DDH). The pediatrician is discussing the long-term evaluation and potential treatment plan for this condition with the parents. Assuming the patient will require the complete spectrum of standard medical intervention due to progressive or refractory disease, arrange the following steps in the chronological sequence they would be appropriately performed, starting from birth and progressing through late infancy.

A 4-week-old boy is brought to the pediatric emergency department with a 12-hour history of high fever, progressive lethargy, and explosive, foul-smelling, bloody diarrhea. His parents report that his abdomen has become massively swollen over the past day. His neonatal history is notable for passage of meconium at 50 hours of life and chronic constipation requiring glycerin suppositories. Vital signs show a temperature of 39.1°C (102.4°F), heart rate of 185/min, respiratory rate of 60/min, and blood pressure of 65/35 mm Hg. Physical examination reveals a lethargic, mottled infant with a markedly distended and tympanic abdomen. Digital rectal examination results in a forceful expulsion of foul-smelling stool and gas. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 4-week-old boy is brought to the emergency department due to irritability and poor feeding that began earlier today. The mother notes he feels warm and is breathing faster than usual. On physical examination, the infant is awake but fussy. Capillary refill is 2 seconds, and peripheral pulses are strong. Vital signs are significant for a heart rate of 280/min, respiratory rate of 50/min, and blood pressure of 84/48 mm Hg. A 12-lead electrocardiogram demonstrates a regular, narrow QRS complex tachycardia with no discernible P waves. Intravenous access is successfully established. Arrange the following management steps in the most appropriate chronological sequence for this patient.