All practice questions

Match each clinical scenario describing a patient with psychotic symptoms to the most appropriate primary psychiatric diagnosis.

A 32-year-old man is court-mandated to attend a substance use disorder treatment program following an arrest for possession of cocaine. The clinic utilizes the Transtheoretical Model of Change to tailor motivational interviewing interventions. Over a two-year period, the patient progresses sequentially through the recognized behavioral stages of recovery. Arrange the following patient statements in chronological order, corresponding to the progression from the earliest stage of change to the latest.

A 28-year-old nulligravid woman presents to the clinic alongside her partner, reporting an inability to conceive after 12 months of regular, unprotected intercourse. She previously experienced predictable 28-day menstrual cycles, but over the past eight months, she has had only two episodes of light vaginal bleeding. The patient notes a generalized lack of energy and an unintentional 8-kg (17.6-lb) weight gain during this period. She also reports the recent appearance of dark, coarse hair on her chin. Her body mass index is 31 kg/m $^2$. Vital signs show a heart rate of 56/min and blood pressure of 112/74 mmHg. Pelvic examination is unremarkable. Transvaginal ultrasonography reveals symmetrically enlarged ovaries, each containing 15 to 20 small subcapsular follicles.

Laboratory studies show the following:
- $\beta$-hCG: negative
- Total testosterone: 65 ng/dL (Reference: 15-70 ng/dL)
- Prolactin: 48 ng/mL (Reference: < 20 ng/mL)
- Thyroid-stimulating hormone (TSH): 11.2 $\mu$ U/mL (Reference: 0.4-4.0 $\mu$ U/mL)
- Free thyroxine (T4): 0.6 ng/dL (Reference: 0.9-1.7 ng/dL)
- Follicle-stimulating hormone (FSH): 4 mIU/mL
- Luteinizing hormone (LH): 3 mIU/mL

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

While recovering from an extensive bowel resection, a 76-year-old man requires blood product replacement due to a postoperative hemoglobin of $6.4 \text{ g/dL}$. His past medical history is notable for ischemic cardiomyopathy with a baseline ejection fraction of $40\%$. Approximately one hour after the second unit of packed red blood cells is initiated, the nursing staff urgently calls the physician to the bedside. The patient reports sudden, severe shortness of breath and a pounding headache. Vital signs are temperature $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), blood pressure $188/96 \text{ mmHg}$, heart rate $115/\text{min}$, and respiratory rate $28/\text{min}$. Oxygen saturation is $85\%$ on room air. Physical examination reveals prominently distended neck veins while sitting upright. Auscultation of the lungs demonstrates diffuse crackles up to the mid-lung fields bilaterally. A third heart sound ($S_3$) is present. The transfusion is immediately halted and supplemental oxygen is provided. Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old woman comes to the clinic for a follow-up visit regarding persistent vaginal discharge and spotting after intercourse. Three weeks ago, she presented with similar symptoms and was diagnosed with cervicitis. A nucleic acid amplification test (NAAT) at that time was positive for *Chlamydia trachomatis* and negative for *Neisseria gonorrhoeae*. She was prescribed a 7-day course of oral doxycycline, which she completed. Her new male sexual partner was also treated, and they abstained from sexual activity for 10 days. Today, her vital signs are within normal limits. Pelvic examination reveals an erythematous, friable cervix with mucopurulent discharge. No cervical motion tenderness or adnexal tenderness is appreciated. A repeat NAAT for *C. trachomatis* and *N. gonorrhoeae* is negative. Wet mount microscopy shows numerous polymorphonuclear leukocytes but no clue cells, trichomonads, or pseudohyphae. Which of the following is the most appropriate next step in management?

A primigravid patient at $36$ weeks gestation comes to the emergency department reporting a $6$-hour history of severe, persistent pain in her right upper abdomen accompanied by nausea. The $29$-year-old reports typical fetal movement and no fluid leakage or uterine contractions. Vital signs include a blood pressure of $162/105\text{ mm Hg}$, a heart rate of $92/\text{min}$, and a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$). On physical examination, there is noticeable swelling of the hands and face, along with significant tenderness in the right upper abdominal quadrant. The fetal heart rate tracing is Category I, showing a baseline of $145/\text{min}$, moderate variability, and positive accelerations.

Laboratory results are as follows:

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

An elderly woman is evaluated in the emergency department for a new, excruciating headache localized to her right temple that began $48$ hours ago. The $72$-year-old patient reports that earlier today, she lost all vision in her right eye for approximately $10$ minutes before it fully returned. Over the past month, she has struggled to get out of bed due to profound stiffness in her shoulders and hips that lasts until mid-day. Additionally, she notes that chewing food has recently become quite painful, prompting her to eat softer meals. Her temperature is $37.9^\circ\text{C}$. On physical examination, her right temporal scalp is exquisitely tender to touch. Initial laboratory evaluation shows an erythrocyte sedimentation rate of $98$ mm/h.

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

A 36-month-old girl is evaluated during a routine pediatric visit. Her father shares concerns raised by her new daycare provider regarding the child's developmental progress. According to the provider, the child is 'falling behind' because she cannot draw a square during arts and crafts and places both feet on each step when walking down the playground stairs. The father also notes that while he easily understands his daughter, extended family members occasionally ask her to repeat herself. The child currently speaks in three-word sentences, easily pedals a tricycle, and engages in imaginative play with her toys. She accurately states her age and gender when asked. Vital signs are normal, and physical examination shows no abnormalities. Based on her current developmental status, which of the following is the most appropriate next step in management?

An elderly male patient, aged 72, comes to the clinic reporting a four-week history of profound fatigue, night sweats, and unintentional weight loss. He notes that these symptoms began roughly two weeks after he underwent a transurethral resection of the prostate for benign prostatic hyperplasia. His temperature in the clinic is 38.2°C (100.8°F), blood pressure is 134/68 mm Hg, and pulse is 96/min. Cardiovascular auscultation reveals a new early diastolic decrescendo murmur best heard at the left third intercostal space. Physical examination also demonstrates nontender, erythematous macules on the palms and soles. Transesophageal echocardiography confirms a mobile, 1.1-cm vegetation on the right coronary cusp of the aortic valve. Two days later, all three sets of blood cultures are positive for *Enterococcus faecalis*. Antimicrobial susceptibility testing indicates that the isolate is susceptible to ampicillin and vancomycin. However, high-level resistance to both gentamicin and streptomycin is detected. Renal function is within normal limits. Which of the following is the most appropriate definitive intravenous antibiotic regimen for this patient?

Patients with various rheumatologic and autoimmune conditions are frequently managed with long-term immunosuppressive therapies, each carrying a unique adverse effect profile. Match each clinical scenario describing an adverse drug effect or mandatory screening requirement to the corresponding disease-modifying antirheumatic drug (DMARD) or immunosuppressant.

A 26-year-old woman, G1P0 at 16 weeks gestation, is brought to the emergency department with a 4-day history of progressively worsening shortness of breath, orthopnea, and severe bilateral leg swelling. She has a 4-year history of systemic lupus erythematosus (SLE) but stopped taking hydroxychloroquine and azathioprine 6 months ago because she wanted a "natural pregnancy." Her temperature is 37.6°C (99.7°F), blood pressure is 165/105 mmHg, pulse is 112/min, and respirations are 28/min. Pulse oximetry shows 89% on room air. Physical examination reveals prominent jugular venous distention. Lung auscultation demonstrates bilateral bibasilar crackles and scattered expiratory wheezes. Cardiac examination shows an S3 gallop. There is 3+ pitting edema extending to the mid-thighs.

Laboratory results are as follows:

Arterial blood gas on room air:
pH: 7.30
pCO₂: 30 mmHg
pO₂: 60 mmHg
HCO₃⁻: 14 mEq/L

Urinalysis shows 4+ protein, numerous red blood cells, and red blood cell casts. Sputum Gram stain reveals rare epithelial cells and no organisms. Chest radiograph with abdominal shielding demonstrates bilateral diffuse alveolar opacities and prominent pulmonary vasculature.

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

Match the following synovial fluid analysis findings to their most likely corresponding joint disorder.

A 67-year-old man presents to the emergency department with a 2-day history of severe, progressively worsening shortness of breath. He reports coughing up frothy, clear sputum and states he had to sleep sitting in a recliner last night due to a feeling of suffocation when lying flat. His medical history includes long-standing hypertension, type 2 diabetes mellitus, and a 45-pack-year smoking history. He takes amlodipine and metformin.

Temperature is 37.0°C (98.6°F), blood pressure is 185/105 mmHg, pulse is 112/min, and respirations are 28/min. Pulse oximetry is 86% on room air. The patient is using accessory muscles of respiration. Jugular venous distension is present up to the angle of the mandible while the patient is sitting at a 45-degree angle. Lung auscultation reveals diffuse, bilateral end-expiratory wheezes and scattered crackles at the lung bases. Cardiac examination shows a regular rhythm, tachycardia, and a distinct S4 gallop. Bilateral 2+ pitting edema is noted in the lower extremities.

Laboratory studies show:
Leukocyte count: 9,200/mm³
Procalcitonin: $0.03$ ng/mL (normal: $< 0.15$ ng/mL)
Arterial blood gas (room air): pH $7.28$, PaCO $_2$ $55$ mmHg, PaO $_2$ $52$ mmHg, HCO $_3^-$ $25$ mEq/L

Chest radiograph shows cardiomegaly, peribronchial cuffing, enlarged pulmonary veins, and prominent interlobular septal lines without focal opacities.

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

A mother brings her 12-month-old son to the pediatric clinic for a routine well-child visit. She expresses concern that her son appears smaller than other children his age at daycare. Upon review of the child's growth chart, the pediatrician notes that the boy's current weight is $9.6 \text{ kg}$ and his length is $75 \text{ cm}$. He has been consistently tracking along the 25th percentile for both parameters since birth, and his developmental milestones are entirely age-appropriate. The physician reassures the mother that her son's growth pattern is completely normal.

Assuming the child has followed classic anthropometric rules of thumb for normal infant growth, which of the following most likely represents this patient's approximate weight and length at birth?

A 64-year-old woman is brought to the emergency department by her husband due to rapidly progressive confusion and a severe headache over the past 14 hours. She has a history of a deceased-donor renal transplant performed three years ago and is currently maintained on a regimen of tacrolimus, mycophenolate mofetil, and low-dose prednisone. On arrival, her temperature is 39.4°C (102.9°F), blood pressure is 98/60 mmHg, heart rate is 118/min, and respiratory rate is 24/min. Physical examination demonstrates marked nuchal rigidity. She is lethargic, oriented only to person, and withdraws appropriately from painful stimuli. Pupils are equal and reactive to light.

Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the immediate management of this patient.

A 32-year-old man comes to the outpatient clinic reporting a 5-month history of worsening fatigue, cold intolerance, generalized weakness, and decreased libido. He struggles to concentrate at work and frequently takes naps during the day. Eight months ago, he was involved in a high-speed motor vehicle collision that resulted in a severe traumatic brain injury. His hospital course was complicated by increased intracranial pressure requiring a 3-week stay in the intensive care unit. He currently takes no medications. Vital signs show a blood pressure of $105/65$ mm Hg and a pulse of $58$/min. Physical examination reveals a slow, deliberate speech pattern and delayed relaxation phase of the deep tendon reflexes. Visual fields are full to confrontation. Laboratory results are as follows:

Which of the following is the most likely underlying mechanism for this patient's current condition?

In the evaluation of patients with suspected idiopathic inflammatory myopathies, specific autoantibody profiles offer critical prognostic information regarding disease progression, expected complications, and treatment response. Match each myositis-specific autoantibody to its most characteristic clinical phenotype.

A $34$-year-old woman, who has never been pregnant, comes to the physician due to a $4$-month history of rapidly progressing facial hair growth and severe acne. Her menstrual periods, previously regular every $28$ days, have completely stopped during this time. The patient has also noted that her voice sounds deeper than usual over the past few weeks. She has no significant past medical history and takes no medications. Her body mass index is $23 \text{ kg/m}^2$. Vital signs show a blood pressure of $124/82 \text{ mmHg}$ and a heart rate of $76/\text{min}$. Physical examination shows significant terminal hair growth on the chin, upper lip, and chest. Pelvic examination demonstrates clitoromegaly and normal vaginal rugae; bimanual examination reveals a normal-sized uterus, but the adnexa are difficult to palpate.

Laboratory studies show:
- $\beta$-hCG: negative
- Prolactin: $14 \text{ ng/mL}$ (Normal: $< 20 \text{ ng/mL}$)
- Thyroid-stimulating hormone: $2.2 \text{ } \mu\text{U/mL}$
- Total testosterone: $210 \text{ ng/dL}$ (Normal: $15-70 \text{ ng/dL}$)
- Dehydroepiandrosterone sulfate (DHEAS): $2.5 \text{ } \mu\text{g/mL}$ (Normal: $0.5-4.0 \text{ } \mu\text{g/mL}$)

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

An antimicrobial stewardship team is auditing the appropriateness of targeted therapies for various complex infections. Match each specific patient scenario and pathogen profile below with its single most appropriate targeted treatment strategy based on current clinical guidelines.

A 39-week gestation infant is delivered via spontaneous vaginal delivery. Immediately after birth, the infant is noted to be apneic, limp, and cyanotic. Arrange the following steps of neonatal resuscitation in the correct chronological order of escalation according to standard guidelines.