All practice questions

Match each patient's clinical presentation and diagnostic findings with the most appropriate targeted antimicrobial regimen.

Match the following developmental milestones, clinical red flags, and pubertal changes to their corresponding expected age thresholds or clinical classifications.

A 45-year-old woman is evaluated in the rheumatology clinic and newly diagnosed with highly active, seropositive rheumatoid arthritis (RA). Baseline radiographs reveal early marginal erosions in the metacarpophalangeal joints. Arrange the following clinical steps in the most appropriate chronological order for her long-term management, assuming she exhibits an inadequate response to each successive pharmacological intervention.

A healthy two-year-old boy presents to the outpatient clinic with his father for a routine health maintenance evaluation. The father reports that the child is active, eats a balanced diet, and sleeps well through the night. On observation, the toddler easily kicks a ball, climbs onto the examination table, and stacks a set of six wooden blocks. When evaluating this patient's speech and language progression, which of the following findings is the most age-appropriate expectation?

A pediatric resident is preparing for a developmental assessment clinic. The attending physician asks the resident to review the expected chronological progression of fine motor and adaptive skills in healthy children. Arrange the following developmental milestones in the correct chronological order from earliest to latest typical age of acquisition.

Emergency medical responders bring a 42-year-old female teacher to the emergency department after she was found profoundly disoriented in her classroom. Her husband reports she has experienced worsening fatigue, diffuse headaches, and nausea over the past three days. She has no significant past medical history and takes no medications. On arrival, her temperature is 38.2°C (100.8°F), blood pressure is 145/90 mmHg, pulse is 112/min, and respirations are 18/min. Physical examination is notable for lethargy, mild scleral icterus, and widespread nonblanching purple pinpoint spots over her lower extremities.

Laboratory studies reveal the following:

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?

A 42-year-old man with a history of intravenous drug use is brought to the emergency department due to severe lower back pain and an inability to move his legs since this morning. For the past week, he has had worsening back pain and subjective fevers. Today, he also noticed he has been unable to urinate. His temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, and pulse is $112/\text{min}$. Physical examination reveals exquisite point tenderness over the L3-L4 spinous processes. Neurologic examination shows $1/5$ strength in bilateral lower extremities, decreased sensation below the umbilicus, and absent patellar and Achilles reflexes. Bedside ultrasound reveals $800\text{ mL}$ of retained urine.

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

A 68-year-old man with a history of type 2 diabetes mellitus is brought to the emergency department by his family due to a severe headache, fever, and progressive confusion over the past 24 hours. On physical examination, his temperature is 39.2°C (102.6°F), blood pressure is 112/72 mmHg, heart rate is 115/min, and respiratory rate is 18/min. He is lethargic, opens his eyes to pain, and is oriented only to his name. Marked nuchal rigidity is present. There are no focal motor deficits, but fundoscopic examination is limited due to patient noncompliance. Place the following management steps in the most appropriate sequential order.

During a routine primary care appointment, a $71$-year-old woman reports experiencing a severe, right-sided headache for the past two weeks. She describes her scalp as being highly sensitive, noting that it hurts simply to brush her hair. Over the last $48$ hours, she has also developed a deep, cramping pain in her jaw that exclusively occurs when she is eating meals. Earlier this morning, she experienced a frightening episode where the vision in her right eye completely went dark for five minutes before spontaneously returning to normal. Her temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$). Physical examination demonstrates a prominent, thickened right temporal artery that is tender to palpation and lacks a palpable pulse. Point-of-care laboratory testing reveals an erythrocyte sedimentation rate of $105\text{ mm/h}$.

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

A 62-year-old man presents to the emergency department with a 5-day history of progressively worsening shortness of breath, orthopnea, and lower extremity swelling. He has a 30-pack-year smoking history but quit 5 years ago. He also has a 10-year history of erosive rheumatoid arthritis. His joint symptoms were poorly controlled with methotrexate alone, so etanercept was added 4 months ago, resulting in significant improvement in his joint pain. His other medical conditions include mild depression, for which he takes fluoxetine. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $154/92 \text{ mm Hg}$, pulse is $108 \text{ min}^{-1}$, and respirations are $24 \text{ min}^{-1}$. Pulse oximetry on room air shows an oxygen saturation of $91\%$. Physical examination reveals jugular venous distention. Lung auscultation demonstrates bilateral bibasilar crackles and scattered expiratory wheezes. Cardiac examination reveals tachycardia with a prominent S3 gallop. There is $2+$ bilateral pitting edema of the lower extremities. Joint examination shows no active synovitis. Laboratory studies show:

Brain natriuretic peptide: $850 \text{ pg/mL}$

Arterial blood gas on room air:
$\text{pH}: 7.49$
$\text{PaCO}_2: 28 \text{ mm Hg}$
$\text{PaO}_2: 64 \text{ mm Hg}$
$\text{HCO}_3^-: 21 \text{ mEq/L}$

Chest radiography reveals cardiomegaly, bilateral alveolar infiltrates, and small bilateral pleural effusions.

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

An emergency medical services team brings a $72$-year-old man to the acute care clinic due to a three-day history of escalating dyspnea and lower extremity swelling. He reports coughing up clear sputum and finds it difficult to lie flat at night. His past medical history includes chronic obstructive pulmonary disease (COPD), diet-controlled hypertension, and osteoarthritis. Current medications include inhaled tiotropium and as-needed albuterol.

His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $156/92\text{ mm Hg}$, pulse is $108/\text{min}$, and respirations are $26/\text{min}$. Pulse oximetry shows $87\%$ on room air. Physical examination reveals jugular venous distention up to $9\text{ cm H}_2\text{O}$. Lung auscultation demonstrates bibasilar crackles extending to the mid-lung fields and prolonged expiration with scattered wheezes. Cardiac examination shows a regular, rapid rhythm with an audible S $_3$ gallop. There is $2+$ pitting edema in both lower extremities.

Laboratory results are as follows:

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

A 12-month-old girl is brought to the clinic for a routine well-child visit. She was diagnosed with acute lymphoblastic leukemia three months ago and is currently receiving induction chemotherapy. The parents are concerned about her development because she cannot run yet. Her mother reports that the child stands independently, takes a few steps on her own, uses a neat pincer grasp, specifically calls her parents "mama" and "dada", and waves goodbye. The parents ask which vaccines she is allowed to receive today. Which of the following is the most appropriate recommendation for this patient?

A 38-year-old man comes to the emergency department due to persistent high fever, drenching sweats, and dark-colored urine. Five days ago, he was evaluated at an urgent care clinic for an expanding, target-shaped erythematous rash on his right calf and a mild headache. The symptoms began a week after a hiking trip in Rhode Island. He was diagnosed with early localized Lyme disease and prescribed oral doxycycline.

Despite adherence to the medication, the rash has faded but his fevers have worsened. Over the past 48 hours, he developed profound fatigue and noticed his eyes appearing yellow. Vital signs show a temperature of 39.4°C (102.9°F), blood pressure of 112/70 mmHg, and heart rate of 115/min. Physical examination is notable for mild scleral icterus. The abdomen is soft, with a spleen tip palpable below the left costal margin.

Laboratory evaluation shows:
- Hemoglobin: 8.6 g/dL
- Platelet count: 88,000/mm³
- Total bilirubin: 3.5 mg/dL
- Direct bilirubin: 0.5 mg/dL
- Lactate dehydrogenase: 720 U/L

A peripheral blood smear reveals intraerythrocytic pleomorphic ring forms. Which of the following is the most appropriate modification to this patient's antimicrobial regimen?

During morning rounds, a 64-year-old woman is evaluated on her third hospital day for management of acute pyelonephritis. She initially presented to the emergency department with a temperature of 38.9°C (102.0°F), right-sided flank pain, and persistent emesis. Blood and urine cultures were drawn, and empiric intravenous piperacillin-tazobactam was initiated.

Today, the patient reports feeling much better. Her flank pain has nearly resolved, and she is eating a regular diet without nausea. She has been afebrile for the past 24 hours. Current vital signs are temperature 37.1°C (98.8°F), heart rate 78/min, and blood pressure 118/76 mm Hg.

The admission blood and urine cultures are now finalizing, both demonstrating heavy growth of *Escherichia coli*. The isolate susceptibility report is as follows:

The patient has no known drug allergies. Her serum creatinine is $0.8$ mg/dL.

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

A 31-year-old man presents to the emergency department with a 5-week history of productive cough, low-grade fever, drenching night sweats, and a $5$-kg ($11$-lb) weight loss. He emigrated from an area with high tuberculosis prevalence three years ago and currently resides in a crowded apartment. His temperature is $38.4^\circ$ C ($101.1^\circ$ F), blood pressure is $118/76$ mm Hg, pulse is $92$/min, and respirations are $20$/min. Oxygen saturation is $96\%$ on room air. Pulmonary examination reveals bronchial breath sounds and crackles in the right upper lung field. A chest radiograph demonstrates a cavitary infiltrate in the right upper lobe.

Arrange the following interventions in the most appropriate chronological order for the management of this patient.

A 32-year-old man is brought to the emergency department due to a 3-day history of progressively worsening, severe right upper quadrant abdominal pain and abdominal swelling. Over the past year, he has experienced significant fatigue and several episodes where his urine appeared abnormally dark, particularly upon waking in the morning. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $112/68 \text{ mm Hg}$, and pulse is $108/\text{min}$. Physical examination reveals scleral icterus, mildly labored breathing, and a markedly distended abdomen with shifting dullness. There is severe tenderness to palpation in the right upper quadrant. The liver edge is palpable $4 \text{ cm}$ below the right costal margin.

Laboratory results are as follows:

Abdominal duplex ultrasonography shows a prominently enlarged liver with moderate ascites and absent color flow signal within the hepatic veins.

Which of the following therapies directly targets the primary etiology of this patient's current condition?

An ambulance brings a 71-year-old male to the emergency department due to severe shortness of breath that awoke him from sleep. He has a known medical background of chronic obstructive pulmonary disease and ischemic heart failure with a reduced ejection fraction. Over the past three days, he has noted increasing difficulty breathing when lying flat and has had to sleep in a recliner chair. He denies fever, chills, or changes in sputum production. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $170/95\text{ mm Hg}$, pulse is $115/\text{min}$, and respirations are $28/\text{min}$. Oxygen saturation is $86\%$ on room air. Examination reveals distended jugular veins when sitting at a 45-degree angle. Pulmonary auscultation demonstrates bilateral crackles up to the mid-lung fields without significant wheezing. Cardiac auscultation reveals a regular tachycardia with an S3 gallop. A bedside chest radiograph demonstrates an enlarged cardiac silhouette, prominent pulmonary vasculature, and bilateral pleural effusions. Which of the following is the most appropriate initial pharmacological intervention for this patient?

A ward nurse urgently requests an evaluation of a 71-year-old male who developed severe, sudden-onset shortness of breath 20 minutes ago. The patient is currently on postoperative day 3 following an elective sigmoid resection for recurrent diverticulitis. His medical history is significant for ischemic heart disease, diet-controlled type 2 diabetes mellitus, and a 40-pack-year smoking history. Over the past 24 hours, he received 3 liters of intravenous lactated Ringer's solution for transient oliguria.

Vital signs are:
- Temperature: 37.2°C (99.0°F)
- Blood pressure: 168/94 mm Hg
- Pulse: 112/min
- Respirations: 26/min
- Oxygen saturation: 87% on room air

Physical examination reveals an agitated, diaphoretic man sitting upright and using accessory muscles of respiration. The jugular veins are distended to the angle of the mandible when the patient is seated at a 45-degree angle. Cardiac auscultation reveals a regular tachycardia with a distinct, low-pitched additional heart sound heard in early diastole. Lung auscultation demonstrates prolonged expiration with diffuse polyphonic wheezing and bilateral moist crackles in the lower lung fields.

Arterial blood gas analysis on room air shows:
- pH: $7.28$
- pCO $_2$: $54$ mm Hg
- pO $_2$: $56$ mm Hg
- HCO $_3^-$: $24$ mEq/L

Which of the following is the most appropriate initial management for this patient?

A physician is evaluating a 64-year-old male patient who reports the sudden onset of profuse, watery diarrhea and lower abdominal cramps that began three days ago. The patient recently completed a 10-day course of clindamycin for a dental abscess. He currently experiences up to nine bowel movements daily. His temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), pulse is $92/\text{min}$, and blood pressure is $118/76\text{ mm Hg}$. Physical examination of the abdomen reveals mild, diffuse tenderness without rebound or guarding. Laboratory results show a leukocyte count of $15,500/\text{mm}^3$. Stool testing is positive for *Clostridioides difficile* toxin via nucleic acid amplification testing. Which of the following is the most appropriate pharmacologic intervention for this patient's current condition?

A 55-year-old man presents to a rural emergency department reporting severe, crushing, substernal chest pain of 45 minutes duration that radiates to his left jaw. He appears diaphoretic and dyspneic. His blood pressure is 145/90 mm Hg and heart rate is 92/min. A 12-lead electrocardiogram demonstrates 4 mm ST-segment elevations in leads V2 through V5. The facility does not have a cardiac catheterization laboratory. The nearest percutaneous coronary intervention (PCI)-capable center is located 140 minutes away by helicopter transport, and weather conditions are clear for flying. Arrange the following management steps in the most appropriate chronological sequence for this patient.