All practice questions

A $29$-year-old nulligravid woman comes to the clinic due to the absence of menstrual periods for the past $6$ months. Prior to this, she had regular $28$-day cycles. Over the same timeframe, she has noted an unintentional $5$-kg ($11$-lb) weight gain, generalized fatigue, and the new onset of coarse dark hair on her upper lip and chin. She is sexually active and uses condoms for contraception, though she and her partner wish to conceive in the next year. Her younger sister was recently diagnosed with polycystic ovary syndrome (PCOS). Vital signs include a blood pressure of $114/72$ mm Hg, a heart rate of $54$/min, and a temperature of $36.6$°C ($97.9$°F). Her body mass index is $31$ kg/m $^2$. Physical examination reveals delayed relaxation of the deep tendon reflexes and moderate facial hirsutism. A urine pregnancy test is negative.

Laboratory results are as follows:

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

A $3$-year-old boy is brought to the pediatric emergency department due to sudden onset of severe, colicky abdominal pain that began $12$ hours ago. Initially, the pain was intermittent, but it has now become constant. He has vomited bilious material four times in the past $6$ hours. The parents report that over the last month, the child had two episodes of painless, dark red rectal bleeding, which resolved spontaneously. On physical examination, the child appears lethargic and toxic. Temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), pulse is $160/\text{min}$, respirations are $32/\text{min}$, and blood pressure is $75/40\text{ mmHg}$. Abdominal examination reveals a rigid, distended abdomen with diffuse guarding, rebound tenderness, and a palpable sausage-shaped mass in the right mid-abdomen. Laboratory studies show:

Following initial fluid resuscitation, which of the following is the most appropriate next step in management?

An obstetric patient in her first trimester is evaluated during a routine health maintenance visit. The $25$-year-old nullipara is currently at $9$ weeks of gestation based on a confirmed ultrasound. She mentions experiencing moderate morning sickness but emphatically denies weight loss, palpitations, heat intolerance, or tremors. Her physical examination, including palpation of the anterior neck, is entirely unremarkable with no thyromegaly or nodules detected. Due to a strong family history of endocrine disorders, a comprehensive thyroid function panel is obtained alongside standard prenatal screening. Laboratory analysis reveals a thyroid-stimulating hormone (TSH) level of $0.1 \text{ } \mu\text{U/mL}$ (Reference: $0.4 - 4.0 \text{ } \mu\text{U/mL}$), a total thyroxine ($T_4$) level of $14.5 \text{ } \mu\text{g/dL}$ (Reference: $5.0 - 12.0 \text{ } \mu\text{g/dL}$), and a free thyroxine (free $T_4$) level of $1.2 \text{ ng/dL}$ (Reference: $0.9 - 1.7 \text{ ng/dL}$). Which of the following physiological mechanisms best explains the laboratory findings observed in this patient?

A 29-year-old nulliparous woman at 40 weeks gestation is admitted to the labor and delivery unit in active labor. Her pregnancy has been uncomplicated. On admission at 09:00, her temperature is 37.2°C (99.0°F), blood pressure is 118/76 mm Hg, and pulse is 82/min. Cervical examination reveals $6$ cm dilation, $90\%$ effacement, and the fetal presenting part at $-1$ station. Spontaneous rupture of membranes occurs shortly after admission, revealing clear amniotic fluid. An intrauterine pressure catheter (IUPC) is placed to monitor contractions.

At 13:00, a repeat cervical examination shows the cervix remains $6$ cm dilated and $90\%$ effaced, with the fetal head at $-1$ station. The IUPC demonstrates 3 contractions per 10-minute period, yielding a total of $160$ Montevideo units (MVUs). The fetal heart rate tracing demonstrates a baseline of 140/min, moderate variability, positive accelerations, and no decelerations. Which of the following is the most appropriate next step in management?

A 15-month-old girl is brought to the pediatric clinic for a 2-day history of low-grade fever, mild cough, and clear rhinorrhea. Her temperature is 37.8°C (100.0°F), and her respiratory rate is 24/min. Lung auscultation reveals transmitted upper airway sounds but no true wheezing or crackles. During the visit, her mother expresses deep concern that the child is developmentally delayed because she only speaks three words and cannot yet run.

Physical examination reveals an active, well-appearing toddler. Skin examination shows eight flat, uniformly hyperpigmented macules measuring 1 to 2 cm in diameter scattered across her chest and back, along with distinct clustering of freckles in both axillae. Neurologic examination shows normal muscle tone and strength. She is able to walk independently and uses a neat pincer grasp to pick up small objects.

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

Emergency medical services bring a 10-year-old boy to the acute care bay after his parents reported severe difficulty breathing at home. He has a documented history of moderate persistent asthma. According to his parents, he has been using his albuterol metered-dose inhaler every hour for the past six hours, but his symptoms have progressively worsened. On presentation, his temperature is $37.1^{\circ}\text{C}$ ($98.8^{\circ}\text{F}$), respiratory rate is $45/\text{min}$, heart rate is $142/\text{min}$, and oxygen saturation is $88\%$ on room air. The patient is visibly anxious, sitting in a tripod position, and can only speak in isolated words. Physical examination highlights prominent suprasternal and intercostal retractions. Lung auscultation reveals prolonged expiration, diffuse high-pitched wheezing across all lung fields, and globally decreased air entry. Which of the following interventions are indicated in the initial, immediate management bundle for this patient? (Select all that apply)

Seeking evaluation for vaginal discomfort, a 23-year-old university student comes to the campus health center. She has experienced a malodorous discharge and mild vulvar itching for the past seven days. The patient reports these symptoms started shortly after she initiated a sexual relationship with a new male partner. Her medical history is unremarkable, and she takes no routine medications. Her vital signs are within normal limits. Pelvic examination displays mild vulvar erythema and a copious, frothy, yellow-green fluid pooled in the posterior vaginal fornix. The exocervix demonstrates multiple small, punctate hemorrhages. Vaginal fluid pH is measured at $6.2$. Microscopic analysis of a saline wet mount reveals an abundance of polymorphonuclear leukocytes alongside actively motile, flagellated protozoa. Which of the following is the most appropriate management plan for this patient?

A 26-year-old primigravida at 39 weeks' gestation is admitted to the labor unit and progresses to the active phase of the second stage of labor. Her pregnancy has been uncomplicated. To successfully navigate the maternal bony pelvis, the fetus must undergo a series of positional changes known as the cardinal movements of labor. Assuming a fetus in a normal occiput anterior presentation, arrange the following cardinal movements in the correct physiological and chronological sequence, beginning with the fetal head entering the pelvis.

A $25$-year-old primigravid woman at $32$ weeks gestation is evaluated in the outpatient clinic. She reports a two-week history of feeling "out of breath" and frequently needing to take deep sighs, particularly when sitting or resting. She has no chest pain, cough, orthopnea, or paroxysmal nocturnal dyspnea. Her pregnancy has been uncomplicated, and she takes a daily prenatal vitamin. Her temperature is $36.8^\circ$ C ($98.2^\circ$ F), blood pressure is $112/68$ mm Hg, pulse is $86$/min, and respirations are $18$/min. Pulse oximetry is $99\%$ on room air. Physical examination reveals clear breath sounds bilaterally. Cardiac auscultation reveals a grade $2/6$ systolic ejection murmur at the left upper sternal border. Trace bilateral lower extremity edema is present. An arterial blood gas analysis on room air reveals the following:

pH: $7.45$
PaCO $_2$: $29$ mm Hg
PaO $_2$: $102$ mm Hg
HCO $_3^-$: $18$ mEq/L

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

A $2$-year-old boy is brought to the emergency department by his parents after they noticed a large amount of maroon-colored stool in his diaper this morning. He has had one additional bloody bowel movement since arrival. The parents report that the child has been completely asymptomatic otherwise; he has had no fever, vomiting, diarrhea, or apparent abdominal pain, and his appetite has been normal. He has no significant past medical history and has met all developmental milestones. Vital signs are temperature $37.1^\circ$ C ($98.8^\circ$ F), blood pressure $95/60$ mm Hg, pulse $115$/min, and respiratory rate $22$/min. Physical examination reveals an alert and playful child. The abdomen is soft, non-distended, and non-tender to palpation, with no palpable masses. Laboratory studies show a hemoglobin level of $10.4$ g/dL and a platelet count of $250,000$/mm $^3$. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A $9$-year-old boy with a known history of sickle cell anemia (HbSS) is brought to the emergency department by his parents. $1$ hour ago, he suddenly developed slurred speech and weakness in his right arm and leg. On presentation, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, heart rate is $105/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals an alert child with a right-sided facial droop and dense right-sided hemiparesis. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 21-year-old university student is evaluated at the student health center at the insistence of his roommate. The roommate is concerned because the patient spends most of his time alone in their shared apartment, intensely studying 'crystal energy fields' and claiming to occasionally perceive auras around people. However, the patient acknowledges that these auras might just be his imagination. During the clinical interview, the patient avoids eye contact and appears highly anxious. He wears a heavy winter trench coat despite it being the middle of summer. His speech is circumstantial and rich in unusual metaphors, yet he remains goal-directed. He explicitly denies hearing voices when no one is present or believing that others are conspiring against him. The patient states he has felt like an 'outsider' for as long as he can remember and has never had close friends. There is no history of distinct depressive or manic episodes. Which of the following is the most likely diagnosis?

Arrange the following clinical events in the correct chronological sequence for the standard screening, diagnosis, and definitive management of a 34-year-old patient who is found to have high-grade cervical dysplasia.

A 28-year-old primigravid woman presents to the clinic at 8 weeks of gestation for her initial prenatal visit. She has no significant past medical history and takes only a daily prenatal vitamin. Her vital signs are within normal limits. Laboratory evaluation reveals a blood type of A, Rh-negative, with a negative antibody screen. The patient intends to pursue all standard recommended prenatal care. Arrange the following routine prenatal screening and prophylactic interventions in the correct chronological sequence in which they should be offered or administered during her uncomplicated pregnancy.

A 14-year-old girl is hospitalized for an acute, severe exacerbation of newly diagnosed ulcerative colitis. Over the past 48 hours, she has been treated with intravenous fluids, methylprednisolone, and prophylactic low-molecular-weight heparin. The nursing staff urgently calls the physician to the bedside due to an abrupt deterioration in her clinical status. The patient reports continuous, excruciating abdominal pain that is no longer crampy. Her temperature is 39.4°C (102.9°F), blood pressure is 84/50 mmHg, heart rate is 142/min, and respiratory rate is 28/min. Physical examination demonstrates a markedly distended, tympanitic abdomen with diffuse rigidity, guarding, and rebound tenderness. Bowel sounds are absent. A portable supine abdominal radiograph reveals a transverse colon diameter of 7.5 cm, loss of normal haustral markings, and mucosal edema, with no free intraperitoneal air.

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

A $28$-year-old primigravid woman at $26$ weeks gestation is evaluated in the clinic for a dull ache in her right lower back and flank over the past week. She reports no fever, chills, nausea, vomiting, dysuria, or changes in urinary frequency. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $110/68\text{ mm Hg}$, and pulse is $82/\text{min}$. Physical examination reveals a gravid uterus consistent with gestational dates. There is mild right-sided flank fullness but no exquisite costovertebral angle tenderness on deep palpation.

Laboratory studies show:
Leukocyte count: $13,500/\text{mm}^3$
Hemoglobin: $11.2\text{ g/dL}$
Blood urea nitrogen: $6\text{ mg/dL}$
Serum creatinine: $0.5\text{ mg/dL}$
Urinalysis: negative for leukocyte esterase, nitrites, and blood; trace protein; $1$-$2\text{ WBCs/hpf}$.

A right upper quadrant and renal ultrasound demonstrates moderate dilation of the right renal pelvis and proximal ureter, which tapers smoothly at the pelvic brim. The left kidney and urinary tract are normal.

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

A pregnant patient, gravida $2$, para $1$, at $41$ weeks and $1$ day gestation is admitted to the labor unit for a scheduled induction of labor due to a post-term pregnancy. She is receiving a continuous intravenous infusion of a synthetic uterotonic agent to stimulate uterine activity. Her medical history is unremarkable, and her previous delivery was an uncomplicated vaginal birth.

Current maternal vital signs reveal a blood pressure of $115/75\text{ mmHg}$, heart rate of $86\text{/min}$, and temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$). Uterine contractions are occurring every $3$ to $4\text{ minutes}$ and palpate as strong. A sterile vaginal examination reveals the cervix is $5\text{ cm}$ dilated, $90\%$ effaced, and at $-1$ station.

Continuous electronic fetal monitoring displays a baseline heart rate of $140\text{/min}$ with moderate variability. Over the past $25\text{ minutes}$, the tracing demonstrates recurrent, symmetric, gradual decreases in the fetal heart rate that begin after the peak of each uterine contraction and slowly return to the baseline after the contraction ends. These decelerations are occurring with approximately $75\%$ of the contractions. The patient is repositioned to her left side and provided with supplemental oxygen, but the fetal heart monitoring pattern remains unchanged.

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

Presenting to the gynecology office for the evaluation of persistent vaginal bleeding, a 39-year-old female reports that her current bleeding episode has lasted for four consecutive weeks. Prior to the onset of this bleeding, she had not menstruated for six months. She has a known medical history of polycystic ovary syndrome (PCOS), diagnosed when she was 22, and obesity. Additionally, she reports a two-year history of episodic, severe unilateral headaches that are reliably preceded by flashing visual zig-zags; she uses over-the-counter ibuprofen for relief. She recently entered a new relationship and specifically requests a daily birth control pill to prevent pregnancy and to help regulate her cycle. Her body mass index is $37 \text{ kg/m}^2$. Vital signs are within normal limits. A urine beta-hCG test performed in the clinic today is negative. Pelvic examination demonstrates a normal-sized, non-tender uterus and no adnexal masses. Which of the following is the most appropriate next step in the management of this patient?

A 2-day-old male neonate is evaluated in the neonatal intensive care unit after two episodes of bilious emesis. He was born at 38 weeks gestation via uncomplicated spontaneous vaginal delivery to a 29-year-old primigravida. Prenatal ultrasonography at 32 weeks revealed polyhydramnios. His temperature is 37.1°C (98.8°F), heart rate is 145/min, blood pressure is 65/40 mm Hg, and respiratory rate is 42/min. Physical examination reveals a soft, non-distended abdomen without guarding, rigidity, or erythema of the abdominal wall. Bowel sounds are decreased. A nasogastric tube is placed, returning 25 mL of dark green fluid. An anteroposterior abdominal radiograph demonstrates a distended stomach and proximal duodenum (double bubble sign), along with a small amount of scattered gas in the distal small and large bowels. There is no pneumatosis intestinalis or free intraperitoneal air. Which of the following is the most appropriate next step in management?

An 8-month-old female infant is brought to the pediatric emergency department due to sudden episodes of severe, inconsolable crying. During these episodes, she draws her knees to her chest. The episodes began 24 hours ago and have progressively worsened in frequency. Earlier today, she began having non-bilious vomiting, which recently transitioned to bilious emesis. Her last bowel movement contained dark red blood and thick mucus.

On physical examination, her temperature is 38.8°C (101.8°F), heart rate is 175/min, respiratory rate is 45/min, and blood pressure is 68/40 mmHg. She appears lethargic and pale. Abdominal examination reveals a rigid, distended abdomen with severe, diffuse tenderness and involuntary guarding. Bowel sounds are absent. Arterial blood gas analysis demonstrates a $pH$ of 7.24, $pCO_2$ of 28 mmHg, and $HCO_3^-$ of 12 mEq/L.

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