All practice questions

Match each complex clinical scenario involving informed consent and refusal of care to the most appropriate legal or ethical management principle.

Review the following clinical encounters involving potential boundary issues, conflicts of interest, or interprofessional disputes. Identify the most appropriate corresponding action or ethical standard for each situation.

An epidemiological investigation is initiated after 18 cases of a mild febrile illness accompanied by an intensely pruritic, vesicular rash in various stages of healing are reported at an elementary school. The epidemic curve displays progressively taller peaks of incident cases separated by intervals of 14 to 21 days. During the investigation, public health officials identify five teachers who were continuously exposed to an infected student in their shared classroom 4 days ago. Serological testing confirms all five teachers lack immunity to the pathogen. Three of the teachers are healthy adults, while two are currently in their first trimester of pregnancy.

Which of the following correctly identifies the transmission dynamics of this outbreak and the most appropriate immediate management for the five exposed teachers?

A first-year resident notices that a peer on the same clinical rotation has been consistently documenting comprehensive physical examinations in the electronic medical record before actually evaluating the patients. This practice of fabricating clinical documentation poses a significant risk to patient care and violates professional ethics. Arrange the following actions in the most appropriate sequential order for addressing and escalating this professionalism breach, starting with the immediate first step and progressing through the chain of command assuming the issue remains unresolved at each prior level.

A primary care physician is evaluating a 5-year-old boy during a scheduled health maintenance visit prior to kindergarten entry. The patient was diagnosed with minimal change disease at age $3$ and recently developed a relapse characterized by heavy proteinuria and periorbital edema. To manage this flare, he has been receiving daily oral prednisone therapy at a dose of $2 \text{ mg/kg/day}$ for the past $3$ weeks. Today, the child feels well, and his edema has significantly improved. Vital signs are within normal limits. A review of his immunization records indicates he is due for his 4- to 6-year vaccine series, including the fifth dose of diphtheria, tetanus, and acellular pertussis (DTaP); fourth dose of inactivated poliovirus (IPV); second dose of measles, mumps, and rubella (MMR); and second dose of varicella vaccines. Which of the following is the most appropriate action regarding this patient's immunizations today?

Match the following fetal heart rate (FHR) tracing patterns observed during labor to their classic underlying physiological or pathological etiologies.

A 34-year-old woman, gravida 4, para 3, is evaluated in the obstetrical triage unit at 37 weeks and 4 days gestation. She complains of a sudden onset of severe, unremitting lower abdominal and back pain that started 90 minutes ago. The patient reports normal fetal movement earlier in the day but denies any vaginal bleeding, leakage of fluid, or recent trauma. Her prenatal course was notable only for mild diet-controlled gestational diabetes. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $112/68\text{ mm Hg}$, and pulse is $118\text{/min}$. On physical examination, the uterus is extremely firm, rigid, and exquisitely tender to light palpation. Pelvic examination reveals a long, closed, and posterior cervix with no visible blood in the vaginal vault. Initial laboratory studies demonstrate a hemoglobin of $10.6\text{ g/dL}$ and a platelet count of $152,000/\text{mm}^3$. Tocodynamometry shows high-frequency, low-amplitude uterine contractions occurring every 1 to 2 minutes with a persistently elevated resting tone. Fetal heart rate monitoring reveals a baseline of $105\text{/min}$, absent variability, and recurrent late decelerations. Which of the following is the most appropriate next step in management?

A 29-year-old woman presents to the office due to the absence of menstruation for the past 8 months. She previously had regular 29-day menstrual cycles since menarche at age 12. She reports no recent changes in weight, strenuous exercise habits, nipple discharge, headaches, or visual disturbances. Her past medical history is unremarkable, and she takes no daily medications. She is sexually active with a male partner and uses condoms inconsistently. Vital signs include blood pressure 110/70 mm Hg, pulse 72/min, and BMI 24 kg/m². Physical examination demonstrates normal breast development, appropriate body hair distribution, and a normal appearing cervix and vaginal vault.

Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's secondary amenorrhea.

A 24-year-old nulligravid woman is evaluated in the hospital on the third day of admission for pelvic inflammatory disease complicated by a 4-cm left tubo-ovarian abscess. On admission, she presented with a temperature of 38.9°C (102.0°F), severe lower abdominal pain, and a leukocyte count of 18,500/mm³. She was started on intravenous cefoxitin and oral doxycycline. Today, she reports feeling much better. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, pulse is 78/min, and respirations are 14/min. Abdominal examination shows significantly decreased tenderness with no rebound or guarding. Pelvic examination reveals markedly improved cervical motion tenderness and a stable left adnexal fullness. She is tolerating a regular diet, and her leukocyte count has decreased to 9,200/mm³. Which of the following is the most appropriate next step in management?

A $29$-year-old primigravid patient at $37$ weeks and $5$ days gestation presents to the obstetric triage unit reporting a sudden gush of clear vaginal fluid occurring $1$ hour ago. Over the past $20$ minutes, she has noticed the fluid becoming increasingly blood-tinged, followed by active, painless vaginal bleeding. She denies abdominal pain or uterine contractions. Her prenatal course was notable for a second-trimester ultrasound showing a velamentous umbilical cord insertion. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $122/78$ mm Hg, and pulse is $88$/min. The maternal abdomen is soft and non-tender. Speculum examination confirms active bleeding from the external cervical os. Continuous fetal monitoring initially showed a baseline of $145$/min with moderate variability, but now demonstrates a sudden, prolonged deceleration to $70$/min lasting for the past $4$ minutes. Which of the following is the most appropriate next step in management?

A 68-year-old woman presents to the clinic reporting a 6-month history of troublesome urinary symptoms. She describes experiencing a sudden, overwhelming need to urinate that is difficult to defer, often resulting in urinary leakage before she can reach the bathroom. She voids approximately 10 times during the day and wakes up 3 times at night to urinate. The patient denies any leakage when coughing, laughing, or lifting heavy objects. She also denies dysuria or hematuria. Over the past two months, she has tried limiting her caffeine intake and following a timed voiding schedule, but her symptoms have not improved. Her medical history is unremarkable. Pelvic examination reveals healthy-appearing vaginal mucosa and no evidence of pelvic organ prolapse. Postvoid residual volume is 30 mL, and a urinalysis is completely normal. Which of the following is the most appropriate next step in management for this patient?

Review the following microscopic descriptions of vaginal secretions prepared with normal saline or potassium hydroxide. Associate each distinct microscopic finding with the most likely corresponding gynecologic infection.

During a routine health maintenance visit, a $34$-year-old woman (G3P3) requests a reliable method of contraception. She also reports that her menstrual periods have become increasingly burdensome over the past $8$ months. Her menses occur regularly every $28$ days but now last for $9$ to $10$ days with the passage of large clots. She must change a super-absorbency pad every $1$ to $2$ hours during the heaviest flow and complains of persistent fatigue. Her medical history is notable for a deep vein thrombosis in her right leg $3$ years ago following an international flight, for which she completed a $6$-month course of anticoagulation. Additionally, she underwent a Roux-en-Y gastric bypass $18$ months ago; her body mass index subsequently decreased from $43 \text{ kg/m}^2$ to $27 \text{ kg/m}^2$. Vital signs are normal. Pelvic examination reveals a normal-sized, mobile uterus with no adnexal masses.

Laboratory evaluation reveals:
Hemoglobin: $9.2 \text{ g/dL}$
Mean corpuscular volume: $74 \text{ fL}$
Thyroid-stimulating hormone: $2.1 \mu\text{U/mL}$
Urine pregnancy test: negative

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

A 29-year-old G2P2 is evaluated in the outpatient setting for secondary amenorrhea that has persisted for 9 months. Her last pregnancy concluded 14 months prior via a spontaneous vaginal delivery, which was immediately complicated by significant uterine atony. This resulted in a massive obstetric hemorrhage necessitating a 4-unit packed red blood cell transfusion. In the postpartum period, the patient noted a complete inability to breastfeed her newborn. Over the most recent six-month interval, she has developed worsening fatigue, an inability to tolerate cold temperatures, and an unintended weight loss of 4 kg (8.8 lb). Before her last pregnancy, her menstrual cycles were highly predictable, occurring every 28 days. Vital signs today show a blood pressure of 92/58 mm Hg and a heart rate of 58/min. Physical examination is remarkable for dry, cool skin and a noticeable delay in the relaxation phase of her deep tendon reflexes. A urine beta-hCG assay is negative. Which of the following laboratory test result patterns is most likely to be present in this patient?

During a routine wellness check, a patient reports noticing small amounts of dark blood on her toilet tissue over the past week. Review of her medical record confirms she is nulliparous, has a body mass index of $34 \text{ kg/m}^2$, and experienced her final menstrual period eight years ago. A pelvic examination reveals a small amount of blood in the vaginal vault with a visually normal cervix and no vaginal lacerations. Which of the following is the most appropriate next step in the management of this patient?

A 59-year-old woman comes to the office due to a 3-month history of continuous urinary dribbling. She says, "I never feel like my bladder is fully empty, and urine just constantly leaks out all day." She has a 20-year history of type 2 diabetes mellitus that is poorly controlled, with a recent hemoglobin A1c of 9.2%. Her current medications include metformin, glipizide, and insulin glargine. On pelvic examination, the vaginal mucosa is pink and well-rugated, and there is no evidence of pelvic organ prolapse. Neurologic examination shows decreased sensation to monofilament testing over the plantar surface of both feet. Which of the following is the most appropriate next step in the evaluation of this patient's urinary symptoms?

Match each clinical vignette describing an adverse reaction during the management of postpartum hemorrhage to the underlying mechanism of action of the responsible pharmacologic agent.

An academic medical center runs a specialized complex contraception clinic. Four patients present seeking highly effective, reversible contraception. Match each patient's presentation and medical history with the single most appropriate contraceptive method based on the World Health Organization Medical Eligibility Criteria (WHO MEC) and potential secondary clinical benefits.

A 68-year-old woman presents to the clinic reporting recurrent, light vaginal bleeding for the past 4 months. Three months ago, she was evaluated at an outside facility for the initial onset of this symptom. At that time, a transvaginal ultrasound was performed, demonstrating a homogeneous endometrial stripe of 2.6 mm and normal-appearing ovaries. A Pap test was negative for intraepithelial lesion or malignancy. She was diagnosed with genitourinary syndrome of menopause and prescribed vaginal estrogen therapy. The patient has been using the estrogen cream twice weekly as directed, but reports that the intermittent spotting has persisted. She takes no other medications and has no history of abnormal Pap smears. Vital signs are within normal limits. Pelvic examination reveals a well-rugated, moist vaginal mucosa. The cervix appears nulliparous and grossly normal, with a small amount of dark blood noted at the external os. The uterus is small, mobile, and non-tender, with no palpable adnexal masses. Which of the following is the most appropriate next step in management?

A hospital administration is addressing a documented pattern of disruptive behavior by an attending surgeon who frequently yells at operating room staff and throws surgical instruments when frustrated. None of these incidents have resulted in direct patient harm, but they have created a highly hostile work environment. Assuming the surgeon's behavior remains refractory and does not improve at any stage, arrange the following institutional and regulatory responses in the correct chronological order of escalation.