All practice questions

A 12-month-old boy is brought to the clinic for a routine well-child evaluation. His mother, who is 18 weeks pregnant, reports that he is doing well but expresses concern that he is not yet walking independently. On evaluation, the infant is able to pull himself to a stand, cruises along the examination table, and uses a neat pincer grasp to pick up small objects. He babbles frequently, says "mama" and "dada" specifically to his parents, and plays peek-a-boo. The infant is up to date on all immunizations administered prior to 12 months of age. His mother asks if his required immunizations for today are safe for her unborn baby. Which of the following is the most appropriate management for this patient?

A pediatric clinic is implementing a new screening tool for early childhood development. The nursing staff is tasked with organizing a chronological checklist of expected developmental milestones to evaluate pediatric patients over their first three years of life. Arrange the following sets of developmental milestones in chronological order from the earliest expected age of acquisition to the latest.

Match each immunocompromised patient scenario with the most appropriate antimicrobial prophylaxis or maintenance regimen.

A $64$-year-old man comes to the clinic with a $3$-week history of worsening joint pain, morning stiffness lasting over an hour, and low-grade fevers. He also reports sharp, left-sided chest pain that worsens with deep inspiration and coughing. His medical history includes heart failure with reduced ejection fraction, hypertension, and bipolar disorder. Five months ago, he was hospitalized for a heart failure exacerbation, and his medical regimen was adjusted. Current medications include carvedilol, spironolactone, hydralazine, isosorbide dinitrate, and lithium. Temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, and heart rate is $78/\text{min}$. Physical examination reveals a pleural friction rub at the left lung base. There is symmetric swelling, warmth, and tenderness of the proximal interphalangeal joints and wrists bilaterally. Laboratory testing shows normal C3 and C4 complement levels, and a positive antinuclear antibody (ANA) titer of $1:640$ with a homogeneous pattern. Anti-double-stranded DNA (anti-dsDNA) antibodies are negative. Which of the following is the most appropriate next step in management?

Match each clinical exposure scenario with the most appropriate post-exposure prophylaxis or initial preventive management strategy.

A 35-year-old woman presents to the emergency department with a sudden onset of severe epistaxis, diffuse petechiae, and profound fatigue. Her initial complete blood count reveals a leukocyte count of 24,000/mm³, hemoglobin of 7.8 g/dL, and a platelet count of 15,000/mm³. Based on the acuity and bleeding diathesis, there is a high clinical suspicion for acute promyelocytic leukemia (APL). Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the optimal management of this patient.

A 42-year-old woman comes to the physician for evaluation of a lump in her neck that she noticed two weeks ago. She has no neck pain, hoarseness, or difficulty swallowing. Over the past two months, she has experienced unintentional weight loss, frequent palpitations, and increased sweating. Vital signs show a heart rate of 110/min and a blood pressure of 135/85 mm Hg. Physical examination reveals warm, moist skin and a fine tremor of the outstretched hands. Palpation of the anterior neck demonstrates a 3-cm, firm, non-tender, mobile mass in the right lobe of the thyroid gland. A targeted bedside neck ultrasound confirms a 3.2-cm solid, hypoechoic nodule with regular margins and no microcalcifications. Laboratory testing reveals:

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

An 82-year-old male resident of a skilled nursing facility is brought to the outpatient clinic for a routine follow-up appointment. His medical history is significant for benign prostatic hyperplasia, type 2 diabetes mellitus, and vascular dementia. The patient relies on a chronic indwelling urinary catheter due to refractory urinary retention. His caregiver reports that he has been at his baseline mental and physical status, eating well, and participating in daily activities without issue. The patient denies any fever, chills, flank pain, or suprapubic discomfort. Vital signs are temperature 37.1°C (98.8°F), blood pressure 130/80 mmHg, pulse 78/min, and respiratory rate 14/min. Physical examination reveals a soft, non-tender abdomen and no costovertebral angle tenderness. As part of a recent facility protocol, a routine urinalysis was performed yesterday which showed 50 white blood cells per high-power field, positive leukocyte esterase, and positive nitrites. Today, the urine culture results return showing >10^5 CFU/mL of multidrug-resistant Pseudomonas aeruginosa. Which of the following is the most appropriate next step in management?

A 45-year-old man presents to the emergency department with epistaxis, bleeding gums, and easy bruising for the past three days. A complete blood count reveals a hemoglobin of $8.2 \text{ g/dL}$, a leukocyte count of $28,000/\mu L$, and a platelet count of $18,000/\mu L$. Coagulation studies demonstrate a prolonged prothrombin time (PT), prolonged activated partial thromboplastin time (aPTT), profoundly low fibrinogen, and elevated D-dimer. A peripheral blood smear shows atypical cells with abundant cytoplasm, heavy azurophilic granulation, and bundles of Auer rods.

Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for this patient.

An 82-year-old woman is evaluated in her long-term care facility for a 1-day history of acute confusion and agitation. She has a history of advanced Alzheimer dementia, hypertension, and osteoarthritis. According to the nursing staff, she has been combative during morning care and is disoriented to place, which represents a significant change from her baseline behavior. She has not exhibited any cough, vomiting, or diarrhea. Vital signs are temperature 37.1°C (98.8°F), blood pressure 138/86 mm Hg, pulse 82/min, and respirations 14/min. Physical examination shows dry mucous membranes and decreased skin turgor. Cardiopulmonary examination is unremarkable. The abdomen is soft and non-tender; there is no suprapubic or costovertebral angle tenderness.

Laboratory results:
Serum sodium: 149 mEq/L
Blood urea nitrogen: 38 mg/dL
Serum creatinine: 1.3 mg/dL (baseline: 0.9 mg/dL)

Urinalysis:
Color: Cloudy yellow
Leukocyte esterase: Positive
Nitrites: Positive
White blood cells: 25/hpf
Bacteria: Numerous

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

A 55-year-old man who has been mechanically ventilated for 5 days in the intensive care unit develops a new fever of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), increased purulent endotracheal secretions, and worsening oxygenation requiring an increase in fraction of inspired oxygen ($FiO_2$) from $0.40$ to $0.60$. Physical examination reveals coarse crackles in the right lower lung field. Laboratory studies show a leukocyte count of $16,000/\text{mm}^3$. A portable chest radiograph reveals a new right lower lobe consolidation. The patient is hemodynamically stable. The clinical team suspects ventilator-associated pneumonia (VAP). Arrange the following management steps in the most appropriate sequential order for this patient.

A 29-year-old woman is evaluated for a four-month history of worsening fatigue, unquenchable thirst, and passing large volumes of pale urine, including waking 4 to 5 times a night to urinate. She also reports clear, bilateral nipple discharge and has not had a menstrual period for six months. Her menstrual cycles were previously regular. She takes no medications and has no history of head trauma or recent pregnancy. Vital signs are within normal limits. Physical examination reveals a visual field defect in the bilateral temporal peripheries. Deep tendon reflexes exhibit a delayed relaxation phase.

Laboratory studies show:
Serum sodium: 147 mEq/L
Serum prolactin: 78 ng/mL (Normal: 4–23)
Thyroid-stimulating hormone (TSH): 1.2 $\mu$ U/mL (Normal: 0.5–5.0)
Free thyroxine (T4): 0.5 ng/dL (Normal: 0.9–1.7)
Urine osmolality: 140 mOsm/kg H $_2$ O

Which of the following mechanisms best explains this patient's clinical and laboratory findings?

A male neonate, aged 16 days, is evaluated in the emergency department in mid-winter due to a 24-hour history of poor feeding, rhinorrhea, and a documented axillary temperature of 38.4°C (101.1°F). He was born at 39 weeks gestation via uncomplicated vaginal delivery and discharged on day 2 of life. On physical examination, the patient appears well-perfused but exhibits mild tachypnea with a respiratory rate of 64/min. Auscultation of the chest reveals diffuse high-pitched expiratory wheezing and mild intercostal retractions. Dermatologic examination shows a splotchy, erythematous macular rash with central tiny yellow papules scattered across the chest and abdomen. A rapid antigen detection test for respiratory syncytial virus (RSV) returns positive. What is the most appropriate single best action in the management of this patient?

A 19-year-old woman comes to the emergency department complaining of sudden-onset, sharp right upper quadrant abdominal pain that worsens with deep inspiration. She also reports a 5-day history of lower pelvic discomfort and spotting between her menstrual periods. She recently became sexually active with a new male partner. Her only medication is an oral contraceptive. Her temperature is 38.3°C (101.0°F), blood pressure is 112/68 mmHg, pulse is 98/min, and respirations are 18/min. Physical examination shows marked right upper quadrant tenderness without guarding or rebound. Murphy sign is negative. There is also bilateral lower quadrant tenderness. Pelvic examination reveals a mucopurulent cervical discharge and pronounced cervical motion tenderness.

A urine pregnancy test is negative. Right upper quadrant ultrasound demonstrates a normal gallbladder without stones, sludge, or wall thickening.

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

A $44$-year-old woman, G $3$ P $3$, comes to the office due to a $1$-week history of continuous, involuntary watery vaginal discharge. Four weeks ago, she underwent a complicated total abdominal hysterectomy for severe endometriosis and large uterine leiomyomas. Her postoperative course was notable for right-sided back pain and a fever of $38.3^\circ\text{C}$ ($101.0^\circ\text{F}$) on postoperative day $14$. She was evaluated at an urgent care clinic where urinalysis was inconclusive, and she was advised to follow up. Her pain and fever spontaneously resolved a week later, which precisely coincided with the onset of the constant vaginal leakage. The patient notes that despite the continuous leakage, she still feels the urge to urinate and voids normally in the toilet every $3$ to $4$ hours. Vital signs today are within normal limits. On pelvic examination, the vaginal cuff appears well-healed with no erythema, but there is pooling of clear fluid in the vaginal vault. A tampon is placed in the vagina, and a dilute methylene blue solution is instilled directly into the bladder via a urethral catheter. Thirty minutes later, the patient is asked to walk around the clinic. The tampon is then removed and shows no blue staining. Which of the following is the most appropriate next step in evaluation?

A 68-year-old man presents to the outpatient clinic reporting a three-week history of worsening swelling in his lower extremities and an uncomfortable sensation of abdominal fullness. He has a 45-pack-year smoking history and was diagnosed with severe chronic obstructive pulmonary disease (COPD) five years ago, for which he takes inhaled bronchodilators and corticosteroids. Vital signs show a blood pressure of 118/76 mmHg, a heart rate of 88/min, and an oxygen saturation of 89% on room air. Physical examination reveals prominent jugular venous distention and a palpable parasternal heave. Auscultation of the chest demonstrates distant breath sounds with a prolonged expiratory phase, but no crackles are heard. A holosystolic murmur is auscultated at the lower left sternal border that increases in intensity with inspiration. Tender hepatomegaly is noted on abdominal palpation. Which of the following pathophysiologic mechanisms is the most direct cause of this patient's cardiovascular findings?

An otherwise healthy 36-year-old female patient presents to the outpatient clinic reporting a 3-week history of spontaneous, unilateral breast discharge. She notes finding small, blood-stained spots on the inside of her bra on the left side. The patient denies any localized breast pain, fever, recent trauma, or palpable lumps. Her menstrual cycles are regular, and she is currently nulliparous. She takes no daily medications and has no family history of breast cancer. On physical examination, visual inspection shows normal breast symmetry without overlying skin changes or nipple retraction. Careful palpation of all quadrants yields no discrete masses, and there is no axillary lymphadenopathy. Gentle pressure applied around the left areola produces a single drop of bloody fluid from a single duct opening. Which of the following is the most likely diagnosis?

A $28$-year-old software engineer presents to the clinic with a $4$-week history of profound sadness, poor concentration, and a $5$-kg ($11$-lb) weight gain. She reports sleeping up to $14$ hours a day and feeling a "heavy sensation" in her arms and legs. She has stopped attending social events and is struggling to meet her project deadlines. Her medical history is unremarkable, and she takes no medications. When asked about past psychiatric symptoms, she recalls a $6$-day period during college when she felt "unstoppable," slept only $2$ to $3$ hours a night without feeling tired, and wrote an entire novel. During that time, friends noted she was speaking much faster than usual, though her behavior did not result in hospitalization or academic failure. Vital signs are within normal limits. Laboratory results show a thyroid-stimulating hormone level of $1.8 \mu U/mL$ (normal: $0.5$ to $5.0 \mu U/mL$) and a negative urine toxicology screen. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

A 9-year-old boy with a history of mild persistent asthma presents to the emergency department with a 24-hour history of worsening cough, shortness of breath, and chest tightness. He recently had symptoms of a mild viral upper respiratory tract infection. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), heart rate of $115/\text{min}$, respiratory rate of $28/\text{min}$, and oxygen saturation of $94\%$ on room air. Physical examination reveals mild intercostal retractions and diffuse expiratory wheezing bilaterally. Which of the following are appropriate initial steps in the management of this patient's condition? (Select all that apply)

A 72-year-old woman comes to the office due to a 6-month history of increasingly severe, involuntary urinary leakage. She describes the urine as "just dripping out" when she transitions from sitting to standing or when walking around her home. The patient underwent a transobturator tape procedure 12 years ago that initially resolved her symptoms, but the leakage has recurred and is now worse. She reports no dysuria, hematuria, or pelvic pain. Medical history includes hypertension, osteoporosis, and well-controlled type 2 diabetes mellitus. Body mass index is $26 \text{ kg/m}^2$. Pelvic examination reveals a well-supported vaginal apex with no anterior or posterior vaginal wall prolapse. A cotton swab (Q-tip) test demonstrates a resting angle of $5^\circ$ and a maximal straining angle of $15^\circ$ from the horizontal. Urodynamic evaluation shows a Valsalva leak point pressure of $45 \text{ cm H}_2\text{O}$ and a post-void residual volume of $20 \text{ mL}$. Detrusor overactivity is absent during cystometry. Urinalysis is unremarkable. Which of the following is the most appropriate next step in management?