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A 34-year-old female is evaluated at the outpatient clinic for persistent exhaustion, a 5-kg (11-lb) weight loss, and failure to resume menses over the past 8 months. Her symptoms began shortly after the delivery of her first child, which was complicated by a prolonged labor and massive postpartum hemorrhage requiring surgical intervention and multiple blood transfusions. She notes feeling lightheaded upon standing and reports she was never able to produce breast milk. Vital signs show a blood pressure of 88/56 mm Hg sitting and 74/48 mm Hg upon standing. Heart rate is 62/min.

Laboratory evaluation shows:
Serum sodium: 128 mEq/L
Serum potassium: 4.0 mEq/L
Thyroid-stimulating hormone (TSH): 1.4 mIU/L (normal: 0.4–4.0 mIU/L)
Free thyroxine (T4): 0.5 ng/dL (normal: 0.9–1.7 ng/dL)

The physician diagnoses hypothyroidism based on the peripheral hormone levels and plans to begin thyroxine replacement therapy. Which of the following is the most appropriate next step in management prior to initiating this medication?

Match each intrapartum fetal heart rate (FHR) abnormality with its primary underlying physiologic or pathophysiologic mechanism.

A 34-year-old woman, gravida 3, para 3, with a history of chronic hypertension and poorly controlled asthma, experiences profuse vaginal bleeding after a precipitous vaginal delivery of a 4300-g (9 lb 8 oz) neonate. The placenta delivers spontaneously and appears intact. On examination, the uterus is soft, boggy, and palpable 4 cm above the umbilicus. Her blood pressure is 90/55 mmHg and her heart rate is 125/min. Immediate continuous bimanual uterine massage is initiated, and a rapid infusion of intravenous oxytocin is administered. Despite these initial measures, brisk vaginal bleeding continues. Arrange the following subsequent interventions in the most appropriate sequential order for managing this patient's ongoing hemorrhage, from first to last.

Evaluate the following histologic, cytogenetic, and clinical descriptions. Pair each specific finding with its corresponding pediatric hematologic or oncologic diagnosis.

A 24-year-old nulliparous woman presents to the gynecology clinic reporting new-onset lower abdominal pain and increased vaginal discharge for the past 3 days. One week ago, she visited a different clinic for a routine wellness examination, during which an endocervical swab was collected for sexually transmitted infection screening. She has not received any treatment since that visit. Her temperature is 38.0°C (100.4°F), blood pressure is 112/74 mm Hg, and pulse is 88/min. Physical examination reveals mild diffuse lower abdominal tenderness. Pelvic examination shows mucopurulent cervical discharge, cervical motion tenderness, and bilateral adnexal tenderness. No adnexal masses are palpable. A point-of-care urine pregnancy test is negative. She is able to tolerate oral intake without nausea. The results of the endocervical nucleic acid amplification test (NAAT) from her visit last week are available in the electronic medical record: the test is positive for Chlamydia trachomatis and negative for Neisseria gonorrhoeae. She has no known drug allergies. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

A 28-year-old woman, gravida 1, para 0, comes to the obstetric clinic at 8 weeks gestation for her initial prenatal visit. She has no significant past medical history, and her pregnancy has been uncomplicated thus far. Her blood type is A negative, and her antibody screen is negative. During the visit, she is counseled on the expected trajectory of routine prenatal care. Arrange the following standard screening tests and prophylactic interventions in the correct chronological order from earliest to latest gestational age, assuming an uncomplicated pregnancy.

A 2-day-old full-term male neonate is evaluated in the neonatal intensive care unit for progressive abdominal distension and bilious emesis. The infant has not passed meconium since birth. Vital signs are within normal limits. Physical examination reveals a markedly distended, tympanic abdomen. Digital rectal examination produces a forceful expulsion of foul-smelling gas and stool, which temporarily relieves the distension. Arrange the following steps in the most appropriate sequential order for the diagnostic evaluation and management of this patient's most likely condition.

An adolescent patient, aged 15, is accompanied by her mother to the outpatient clinic for evaluation of delayed puberty. She reports that she has never experienced a menstrual period. On physical examination, her height is at the 3rd percentile for her age. She has Tanner stage 1 breast development and Tanner stage 1 pubic hair. Her vital signs are within normal limits. Assuming the patient's evaluation follows the most likely etiologic pathway for her clinical presentation, arrange the following diagnostic and management steps in the most appropriate chronological order.

A 29-year-old woman, gravida 2, para 1, at 41 weeks gestation is admitted to the labor and delivery unit for induction of labor due to a post-term pregnancy. She is started on an intravenous oxytocin infusion. Two hours later, the electronic fetal monitor displays contractions occurring every 1 to 1.5 minutes and lasting 60 to 75 seconds. The fetal heart rate baseline is 135/min with minimal variability. The tracing also demonstrates recurrent, smooth, gradual decreases in the fetal heart rate that begin after the peak of each contraction and return to baseline after the contraction ends. The patient's blood pressure is 118/76 mm Hg, and her pulse is 88/min. Cervical examination reveals 5 cm dilation, 80% effacement, and -1 station. Which of the following is the most appropriate next step in management?

A 20-year-old female university student is evaluated in the emergency department for severe, bilateral pelvic pain, vomiting, and subjective fever that began two days ago. She had a new sexual partner last month and uses oral contraceptives inconsistently. Vital signs show a temperature of 39.4°C (102.9°F), pulse of 118/min, and blood pressure of 108/68 mm Hg. Abdominal examination reveals right and left lower quadrant tenderness with voluntary guarding. Speculum examination shows profuse yellow cervical discharge. Bimanual examination elicits significant pain upon movement of the cervix and a tender, boggy mass in the right adnexal region.

Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient.

An otherwise healthy $61$-year-old nulliparous female seeks medical advice due to a recent episode of brownish vaginal discharge. She states that the discharge appeared on her undergarments intermittently over the last $4$ days. Her last menstrual period occurred a decade ago. She currently takes a daily multivitamin and calcium supplement. Her body mass index is $23 \text{ kg/m}^2$. On pelvic examination, the external genitalia and vagina are atrophic. A scant amount of dark blood is visible at the cervical os, but the cervix is otherwise grossly normal and smooth. Bimanual palpation reveals a small, anteverted uterus and no palpable adnexal abnormalities. Transvaginal ultrasonography reveals an echogenic endometrial stripe measuring $7 \text{ mm}$. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old woman, gravida 2, para 1, at 24 weeks gestation presents to the clinic with a 2-day history of mild right-sided flank discomfort. She denies dysuria, urinary frequency, hematuria, fever, chills, or vaginal bleeding. Her temperature is 37.1 °C (98.8 °F), blood pressure is 112/70 mm Hg, pulse is 82/min, and respiratory rate is 14/min. Physical examination reveals a gravid uterus consistent with gestational age and mild right costovertebral angle tenderness. Fetal heart tones are 145/min. Urinalysis shows no white blood cells, red blood cells, leukocyte esterase, or nitrites. A comprehensive metabolic panel is within normal limits. A renal ultrasound demonstrates mild dilation of the right renal pelvis and proximal ureter without evidence of nephrolithiasis. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a gynecologic condition with the most appropriate corresponding management step.

A 29-year-old female patient is evaluated in the outpatient clinic for secondary amenorrhea, having not experienced a menstrual period for the past seven months. Her prior cycles were regular. She also reports a spontaneous, bilateral milky nipple discharge and intermittent frontal headaches over the past few weeks. She denies visual changes, temperature intolerance, or recent weight fluctuations. Vital signs include a blood pressure of 118/76 mm Hg, heart rate of 72/min, and respiratory rate of 14/min. Her body mass index is 23 kg/m². Visual field testing by confrontation reveals no deficits. Arrange the following clinical steps in the most appropriate chronological sequence for the evaluation and management of this patient's condition.

A 14-month-old boy is evaluated in the pediatric ward due to a new-onset fever and worsening work of breathing. He was admitted 3 days ago for respiratory distress secondary to respiratory syncytial virus (RSV) bronchiolitis. Yesterday, he was weaning off supplemental oxygen and tolerating oral feeds well. Today, his temperature is 39.0°C (102.2°F), blood pressure is 90/55 mm Hg, pulse is 155/min, and respiratory rate is 55/min. Pulse oximetry shows 91% on room air. Physical examination reveals intercostal retractions and new localized crackles over the right lower lung field, along with persistent diffuse expiratory wheezing. A chest radiograph demonstrates a new lobar consolidation in the right lower lobe. Blood cultures obtained during a febrile episode earlier today are rapidly growing Streptococcus pneumoniae that is susceptible to penicillin. Which of the following interventions are indicated in the current management of this patient? (Select all that apply)

During a routine well-child visit, the mother of a $4$-year-old girl expresses concern about multiple new bruises on her daughter's legs over the past few days. The mother notes the child had a self-resolving upper respiratory tract infection approximately three weeks prior. The patient is otherwise active and has no history of excessive bleeding, epistaxis, or melena. Physical examination reveals a well-appearing, playful child. Vital signs are within normal limits for age. Skin examination shows scattered petechiae and small ecchymoses confined to the bilateral lower extremities. There is no jaundice, lymphadenopathy, or hepatosplenomegaly.

Laboratory evaluation demonstrates:
Hemoglobin: $12.8 \text{ g/dL}$
Leukocyte count: $8,200/\text{mm}^3$ (normal differential)
Platelet count: $16,000/\text{mm}^3$

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

Emergency medical services bring a primigravid patient at $36$ weeks gestation to the obstetric triage unit due to altered mental status. The $31$-year-old patient has a two-day history of persistent nausea, vomiting, and right-sided abdominal pain. According to her partner, she became progressively lethargic this morning. Her prenatal course was previously uncomplicated. Vital signs include a blood pressure of $132/84\text{ mmHg}$, heart rate of $105\text{/min}$, and temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$). Physical examination is notable for scleral icterus, dry mucous membranes, and tenderness to palpation in the right upper quadrant without guarding. Continuous fetal monitoring reveals a baseline heart rate of $140\text{/min}$ with moderate variability and no decelerations. Initial laboratory studies reveal:

Which of the following is the primary pathophysiologic mechanism responsible for this patient's most likely diagnosis?

A $6$-year-old boy is brought to the clinic by his parents due to fatigue and yellowish discoloration of his eyes for the past $3$ days. He had a mild upper respiratory tract infection one week ago. His past medical history is unremarkable, and his immunizations are up to date. Family history is notable for a paternal aunt who underwent an unexplained splenectomy in her twenties. Vital signs are within normal limits. Physical examination reveals scleral icterus, pale conjunctivae, and a palpable spleen edge $4 \text{ cm}$ below the left costal margin. Laboratory studies show the following:

Direct antiglobulin (Coombs) testing is negative.

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

A 26-year-old primigravida at 39 weeks gestation is in the active phase of the second stage of labor. The fetus is in a cephalic presentation and the fetal head is descending through the maternal pelvis. Arrange the following cardinal movements of labor in the correct chronological sequence as the fetus navigates the maternal birth canal.

A 4-year-old boy is brought to the pediatric emergency department by his parents due to recurrent episodes of severe abdominal pain that started 12 hours ago. During the episodes, he cries inconsolably and pulls his knees to his chest; between episodes, he appears exhausted and lethargic. He has had two episodes of bilious emesis. His last bowel movement consisted of dark red, gelatinous stool. Temperature is 37.2°C (99.0°F), heart rate is 125/min, blood pressure is 95/60 mm Hg, and respiratory rate is 24/min. Physical examination reveals a palpable, sausage-shaped mass in the right middle quadrant. An abdominal ultrasound demonstrates a "target sign." An ultrasound-guided hydrostatic enema is performed, successfully reducing the obstruction. A detailed post-reduction ultrasound identifies a 3.5-cm blind-ending tubular structure protruding from the antimesenteric border of the distal ileum. The patient is now pain-free and resting comfortably. Which of the following is the most appropriate next step in management?