All practice questions

During standard prenatal care, a clinician monitors various clinical and developmental landmarks to ensure a normal trajectory of fetal growth and maternal adaptation. Arrange the following expected clinical milestones in the chronological order they typically occur during a normal, uncomplicated pregnancy, from earliest to latest gestational age.

A 3-week-old boy is brought to the pediatric clinic by his mother because his 5-year-old sister developed a diffuse, pruritic, vesicular rash 2 days ago and was subsequently diagnosed with chickenpox. The mother reports having had a documented case of chickenpox during her own childhood. The patient was born prematurely at 27 weeks gestation and was recently discharged from the neonatal intensive care unit. Over the past 24 hours, the neonate has developed clear rhinorrhea and a mild cough. His temperature is 37.2°C (99.0°F), pulse is 150/min, respirations are 48/min, and oxygen saturation is 97% on room air. Physical examination shows a well-appearing neonate with scattered erythematous macules and papules on his chest. Auscultation of the lungs reveals mild, bilateral expiratory wheezes. Which of the following is the most appropriate next step in management for this patient?

Following a fall from a second-story residential roof, a 54-year-old male is evaluated in the trauma center. He was reportedly cleaning gutters when he lost his balance and fell approximately 20 feet (6 meters) onto the grass below. The patient is awake, alert, and secured to a rigid backboard with a cervical collar.

Vital signs are:
Temperature: 36.6°C (97.9°F)
Heart rate: 122/min
Blood pressure: 80/50 mm Hg
Respiratory rate: 22/min
Oxygen saturation: 96% on room air

Physical examination reveals a patent airway with midline trachea. Breath sounds are clear and equal bilaterally. Heart sounds are normal without murmurs, rubs, or gallops. His abdomen is soft, non-distended, and non-tender to deep palpation, though he notes he cannot feel the examiner's hands well. The pelvis is stable to anterior-posterior and lateral compression. Neurologic examination reveals flaccid paralysis and areflexia of both lower extremities, with a complete loss of pain, temperature, and light touch sensation below the level of the umbilicus. Upper extremity strength and sensation are intact. Two large-bore peripheral intravenous lines are established, and a bolus of warm isotonic crystalloid is initiated.

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

A 62-year-old male presents to the emergency department six days after undergoing an elective open umbilical hernia repair with mesh. He reports a new onset of severe, throbbing pain at the surgical site that began yesterday, accompanied by subjective chills. His medical history includes type 2 diabetes mellitus, obesity, and chronic venous insufficiency characterized by long-standing, stable bilateral ankle edema. Vital signs upon triage are temperature 38.8°C (101.8°F), blood pressure 130/82 mm Hg, pulse 102/min, and respirations 16/min. Oxygen saturation is 98% on room air. Cardiopulmonary auscultation reveals clear breath sounds bilaterally without crackles or wheezes. Abdominal examination demonstrates a 5-cm area of marked erythema and induration surrounding the incision, along with a palpable fluctuant mass deep to the suture line. Purulent fluid is actively weeping from the central portion of the wound. Which of the following are the most appropriate immediate next steps in the management of this patient? (Select exactly 2)

A 42-year-old woman is brought to the emergency department by her husband due to a 2-day history of worsening confusion, slurred speech, and an unsteady gait. She also reports several episodes of severe nausea and vomiting. Her medical history is significant for bipolar I disorder, which has been well-controlled on a stable dose of lithium carbonate for the past 4 years. Two weeks ago, she was evaluated by her primary care physician for newly diagnosed essential hypertension, and a daily medication was added to her regimen. Her temperature is 37.1°C (98.8°F), blood pressure is 128/82 mmHg, and pulse is 84/min. On physical examination, the patient appears lethargic. Neurological examination reveals a coarse, irregular resting tremor in both hands and truncal ataxia. Which of the following medications was most likely recently prescribed to this patient?

Match each postoperative clinical presentation following a gynecologic procedure to the most likely underlying surgical complication or injured structure.

A term male neonate (gestational age: 39 weeks, birth weight: 3200 g) is born at home to a 28-year-old multigravida mother who received no prenatal care. APGAR scores were 7 and 8 at 1 and 5 minutes, respectively. At 48 hours of life, the infant is brought to the emergency department due to extreme jaundice, profound lethargy, and failure to feed. Vital signs are: Temperature 36.8°C, Heart rate 110/min, Respiratory rate 35/min, and SpO2 98% on room air.

Initial laboratory results are as follows:

The infant is at immediate risk for severe bilirubin-induced neurologic dysfunction. Arrange the following clinical manifestations and pathophysiological events in the correct chronological sequence, representing the classic progression of this condition from the ongoing acute insult to the permanent neurologic sequelae of kernicterus.

Match each patient's clinical presentation with the most likely corresponding pathophysiologic mechanism or urodynamic diagnostic finding.

A 68-year-old woman is evaluated in the hospital on the third day of admission for acute pyelonephritis. She initially presented with fever, right-sided flank pain, nausea, and vomiting. She was empirically started on intravenous piperacillin-tazobactam. Today, the patient reports feeling much better. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $126/82\text{ mm Hg}$, heart rate is $78\text{/min}$, and respiratory rate is $14\text{/min}$. Physical examination shows resolution of costovertebral angle tenderness. She is tolerating a regular diet without nausea.

The urine culture obtained on admission has finalized, showing $>10^5\text{ CFU/mL}$ of *Escherichia coli*. Susceptibility testing results are as follows:

Blood cultures obtained on admission show no growth to date.

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

A 48-year-old woman with a history of bipolar I disorder is brought to the emergency department by her husband due to progressive confusion, a coarse hand tremor, and an unsteady gait over the last three days. Her psychiatric condition has been stable on a fixed dose of lithium carbonate for the past five years. Two weeks ago, she was diagnosed with essential hypertension and started on a new antihypertensive medication by her primary care provider. On physical examination, she appears lethargic, has a coarse resting tremor in both hands, and demonstrates ataxia on finger-to-nose testing. Vital signs are within normal limits except for a blood pressure of 128/82 mmHg. Which of the following antihypertensive medications was most likely prescribed to this patient?

Correlate each specific clinical scenario involving a gynecologic infection (or related incidental finding) with its most appropriate, guideline-concordant next step in management.

Match each pediatric patient's clinical presentation with the statement that best describes the precise underlying pathophysiologic mechanism of their condition.

A 2-year-old boy is evaluated in the emergency department for a persistent fever of $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$) that has lasted for 6 days despite regular use of acetaminophen. His mother notes he has been unusually irritable, has poor oral intake, and developed a mild cough today. On physical examination, the child has bilateral bulbar conjunctival injection without purulent discharge. His lips are noticeably erythematous, dry, and fissured. A $2.5\text{ cm}$ firm, tender lymph node is palpated in the right anterior cervical chain. A diffuse, polymorphous maculopapular rash is visible across his trunk and perineum. His hands and feet exhibit non-pitting edema and distinct erythema. Respiratory rate is 42/min, and oxygen saturation is 97% on room air. Lungs are clear to auscultation bilaterally. Cardiac examination reveals tachycardia but a regular rhythm with no murmurs. What is the most appropriate next step in the management of this patient's condition?

A 15-year-old adolescent with cystic fibrosis and pancreatic insufficiency is evaluated in the outpatient pulmonary clinic for a 4-week history of worsening productive cough, malaise, and subjective low-grade fevers. He reports expectorating thick, brownish, plug-like sputum. His daily maintenance regimen of dornase alfa, hypertonic saline, and chest physiotherapy has not alleviated the symptoms. Pulmonary function testing performed today shows a forced expiratory volume in 1 second (FEV1) of 60% of predicted, a significant decline from his baseline of 84% recorded two months ago. Vital signs show an oxygen saturation of 95% on ambient air. Lung auscultation reveals prominent bilateral expiratory wheezes and coarse upper lobe crackles. A complete blood count is notable for an absolute eosinophil count of 1,250/mm³. Total serum IgE is markedly elevated at 1,650 IU/mL. High-resolution computed tomography of the chest demonstrates new upper lobe central bronchiectasis with scattered mucous plugging and fleeting infiltrates. Which of the following are indicated in the initial pharmacological management of this patient's current condition? (Select all that apply)

A 7-month-old boy is brought to the outpatient clinic by his mother due to a two-week history of unusual movements. The mother states that shortly after waking from naps, the infant suddenly flexes his head and pulls his arms forward synchronously. These episodes last for a few seconds and occur in clusters of 10 to 15. Prior to this, he had been babbling and rolling over, but he has stopped performing these skills over the past week. Vitals are: temperature 37.0°C (98.6°F), heart rate 110/min, respiratory rate 28/min, and blood pressure 90/55 mm Hg. Neurological examination reveals axial hypotonia and poor head control. Skin examination is notable for three 1.5-cm elliptical, hypopigmented macules on the trunk and right thigh. An electroencephalogram demonstrates a disorganized pattern of chaotic, high-amplitude slow waves and multifocal spikes. Which of the following is the most appropriate initial pharmacotherapy for this patient's condition?

A 28-year-old primigravida at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Her prenatal course was uncomplicated. Currently, her blood pressure is 118/76 mm Hg, heart rate is 82/min, and temperature is 37.1°C (98.8°F). Vaginal examination reveals that the cervix is dilated to 6 cm, 90% effaced, with the fetal head at +1 station. External fetal monitoring shows a baseline fetal heart rate of 140/min with moderate variability. During uterine contractions, there are recurrent, symmetric decreases in the fetal heart rate to 130/min. The onset, nadir, and recovery of each fetal heart rate decrease precisely align with the beginning, peak, and end of the respective uterine contraction. Which of the following is the most appropriate next step in management?

A 24-year-old primigravida at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Her pregnancy has been uncomplicated. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, and pulse is 82/min. Epidural anesthesia is placed for pain management, and an oxytocin infusion is started to augment labor. Two hours later, a cervical examination reveals that the cervix is 6 cm dilated, 90% effaced, and the fetal head is at -1 station. Uterine contractions are occurring every 2 to 3 minutes and palpate as strong. The fetal heart rate tracing shows a baseline of 140/min with moderate variability. There are recurrent, gradual decreases in the fetal heart rate that begin after the peak of each uterine contraction and return to baseline after the contraction ends. Which of the following is the most appropriate next step in management?

A 68-year-old man is evaluated on the surgical ward due to worsening respiratory distress. He is currently on his third postoperative day following a partial colectomy with primary anastomosis for a localized colon adenocarcinoma. His medical history is significant for hypertension, type 2 diabetes mellitus, a 35-pack-year smoking history, and an anterior wall myocardial infarction three years ago. Since the operation, he has been receiving intravenous lactated Ringer solution at a continuous rate of 125 mL/h.

His temperature is 37.7°C (99.9°F), blood pressure is 156/92 mm Hg, pulse is 114/min and regular, and respirations are 26/min. Pulse oximetry reveals an oxygen saturation of 88% while breathing ambient air.

Physical examination shows a distressed patient sitting on the edge of the bed and using accessory muscles of respiration. Inspection of the neck reveals distension of the jugular veins when the patient is reclined at a 45-degree angle. Pulmonary auscultation demonstrates bilateral coarse crackles in the lower two-thirds of the lung fields, accompanied by scattered expiratory wheezes. Cardiac auscultation reveals a regular tachycardia, normal S1 and S2, and a low-frequency diastolic sound heard best at the cardiac apex. The surgical incision is clean, dry, and intact with no surrounding erythema. The bilateral lower extremities exhibit 1+ pitting edema.

Which of the following is the most appropriate next step in the management of this patient's respiratory distress?

A hospital's quality improvement committee is reviewing a series of diagnostic errors to identify underlying human factors and cognitive biases. The committee aims to develop targeted educational interventions to improve patient safety. Match each clinical scenario describing a diagnostic error to the specific cognitive bias that best explains the physician's reasoning flaw.

A 34-year-old man comes to the clinic for an urgent visit after being notified that his nephew, whom he babysat for several hours 2 days ago, has just been diagnosed with laboratory-confirmed measles. The patient feels well and reports no fever, coryza, cough, or rash. His medical history is significant for severe, fistulizing Crohn disease, for which he is currently treated with infliximab and prednisone ($40$ mg daily). He recalls receiving all of his childhood vaccines but does not have his immunization records available. His vital signs are within normal limits, and physical examination is unremarkable. Which of the following is the most appropriate next step in management?