All practice questions

A 42-year-old woman is brought to the trauma bay by helicopter emergency medical services after crashing her snowmobile into a fence at high speed. She complains of severe abdominal pain. Her temperature is 36.5°C (97.7°F), blood pressure is 76/45 mm Hg, and pulse is 128/min. She is lethargic but appropriately answers questions. The airway is clear, and the trachea is midline. Breath sounds are clear and equal bilaterally. Jugular venous pressure is not elevated. The abdomen is distended, rigid, and exhibits diffuse guarding. A bedside focused assessment with sonography for trauma (FAST) demonstrates a significant anechoic stripe in the hepatorenal recess. Two large-bore intravenous lines are established, and crystalloid fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A 28-year-old woman is brought to the emergency department by law enforcement after she was found walking barefoot in the center of a busy interstate highway. During the psychiatric evaluation, she displays a flat affect and disorganized speech. She calmly explains that she is an emissary of an extraterrestrial civilization and must immediately return to the highway to await her mothership. She is medically stable, unarmed, and not acutely aggressive, but she repeatedly attempts to walk out of the examination room, stating, 'You have no right to keep me here, and I will not take any of your poisons.' Arrange the following clinical and legal interventions in the most appropriate chronological order for managing this patient's admission and ongoing psychiatric care.

Match each patient's clinical presentation with the most likely corresponding neuroimaging or ancillary diagnostic finding.

During morning rounds on the inpatient psychiatric unit, a medical team is evaluating a patient with schizoaffective disorder. The 34-year-old man's psychotic symptoms were previously refractory to numerous medication trials but are now well-controlled on clozapine. However, over the past week, the nursing staff reports that he has become increasingly hyperactive and irritable, pacing the halls and sleeping less than two hours per night. The team diagnoses an acute manic episode and decides to initiate an additional mood-stabilizing medication. A review of his morning laboratory results shows an absolute neutrophil count of 2,800/mm³. Which of the following medications should the team strictly avoid prescribing due to the risk of a synergistic and potentially life-threatening adverse effect?

Emergency medical services transport a 30-year-old factory worker to the regional trauma center after an industrial flash fire. The primary survey confirms a patent airway, symmetric breath sounds, and stable hemodynamics. Secondary evaluation of the patient's integumentary system reveals partial-thickness and full-thickness burns covering the entire anterior aspect of his trunk as well as the entire anterior aspect of his left leg. The genital region, head, posterior torso, arms, right leg, and posterior left leg are completely spared. Based on the standard adult Rule of Nines, what is the estimated percentage of total body surface area affected by these burns?

A 32-year-old woman presents to the outpatient clinic 3 weeks after surviving a traumatic emergency plane landing as a passenger. She describes having severe, recurrent nightmares about the event, hypervigilance, and feeling detached from her loved ones. She has refused to fly since the incident and has taken a leave of absence from her job as a corporate executive. She also reports feeling persistently 'down' and fatigued. Her past psychiatric history is significant for bipolar I disorder, but she discontinued her prescribed mood stabilizer 6 months ago. For the past month, she has been taking daily over-the-counter St. John's wort to manage her low mood. She is highly distressed and asks the physician not to disclose her visit to her company's human resources department, which requires medical clearance for her leave. The physician determines she meets the criteria for acute stress disorder. Which of the following are the most appropriate actions in the management of this patient? (Select 2)

A $19$-year-old male college student is brought to the emergency department by his roommate due to bizarre behavior and severe agitation over the past $24$ hours. The roommate reports that the patient has been barricading the door, claiming that hidden cameras are recording him. The patient has a history of major depressive disorder, for which he takes citalopram. He recently developed a mild upper respiratory infection and has been drinking multiple bottles of over-the-counter cough syrup daily to experience a "euphoric high." Temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse is $126/\text{min}$, respirations are $22/\text{min}$, and blood pressure is $155/95\text{ mm Hg}$. Physical examination reveals a profusely diaphoretic, tremulous young man. Neurologic examination demonstrates bilateral hyperreflexia and prominent spontaneous clonus in the lower extremities. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old woman is examined on the fourth day of her recovery following an elective low anterior resection for rectal cancer. She reports experiencing new-onset lower abdominal discomfort over the past 12 hours. The patient has had an indwelling urethral catheter in place since the operation to prevent postoperative urinary retention. Her temperature is 38.4°C (101.1°F), blood pressure is 118/76 mm Hg, heart rate is 92/min, and respiratory rate is 16/min. Physical examination shows a soft abdomen with mild tenderness localized to the suprapubic region. The midline abdominal surgical incision is well-approximated, dry, and lacks any surrounding erythema or induration. The patient's lungs are clear to auscultation bilaterally, and there is no edema or tenderness in her lower extremities. Which of the following is the most appropriate next step in the management of this patient's fever?

A 28-year-old woman is brought to the outpatient clinic by her husband for evaluation of abnormal behavior and low mood. For the past 10 weeks, she has exhibited profound sadness, extreme fatigue, and hypersomnia, often sleeping 14 hours a day. Her husband reports that for the last 6 weeks, she has been responding to unseen stimuli and admits to hearing a persistent voice calling her a "worthless failure."

Two years ago, the patient experienced a 2-week episode of euphoric mood, boundless energy, and rapid speech. During that time, she slept only 2 hours a night and spent the couple's entire savings on unneeded luxury goods, which required a brief psychiatric hospitalization.

She currently takes no medications but asks if she can be started on a combination of a selective serotonin reuptake inhibitor (SSRI) and a monoamine oxidase inhibitor (MAOI), as she read online that this combination is highly effective for severe depression.

Laboratory evaluation shows:
Thyroid-stimulating hormone (TSH): 1.8 µU/mL (Normal: 0.5-5.0 µU/mL)
Free thyroxine (T4): 0.5 ng/dL (Normal: 0.9-1.7 ng/dL)

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

A 17-year-old girl is admitted to the hospital for medical stabilization of severe anorexia nervosa, restricting subtype. Her body mass index on admission is $12.5 \text{ kg/m}^2$. Her home medication of fluoxetine is continued. Routine admission laboratories reveal a normal thyroid-stimulating hormone (TSH) level with a low total T3 and low-normal free T4. Due to her profound malnutrition, continuous nasogastric tube feeding is initiated at a high caloric rate to promote rapid weight gain. On the third day of hospitalization, the patient suddenly develops significant shortness of breath, a cough productive of pink frothy sputum, and orthopnea. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse is $118\text{/min}$, respirations are $28\text{/min}$, and blood pressure is $92/60\text{ mmHg}$. Physical examination reveals distinct jugular venous distention and bilateral basilar lung crackles. Which of the following is the most likely primary mechanism for this patient's acute clinical deterioration?

Correlate the following clinical scenarios involving psychotropic polypharmacy with their underlying pharmacokinetic or pharmacodynamic interaction mechanisms and resulting clinical consequences.

Match each patient presentation with the mechanism of action of the most appropriate pharmacotherapy for their clinical scenario.

A variety of gynecologic procedures carry specific, well-described risks due to the anatomic relationships and physiologic changes involved. For each surgical intervention described below, select the complication or clinical presentation most uniquely associated with it.

A 48-month-old boy presents for pediatric evaluation at the urging of his early childhood educator. The educator expressed strong concerns regarding potential Attention-Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD). According to the school's behavioral report, the child is unable to sit quietly during a 45-minute continuous group reading session, frequently fidgets, and often engages in parallel play alongside his peers rather than joining their cooperative group games. The parents report that at home, he speaks in 4-word sentences, consistently uses pronouns correctly, and enjoys pedaling his tricycle. During the clinic visit, the child successfully copies a cross on a piece of paper but is unable to copy a triangle. He demonstrates robust, reciprocal eye contact and uses index finger pointing to indicate interest in toys across the room. Based on this clinical presentation, which of the following statements are correct? (Select all that apply)

A 35-year-old woman is brought to the clinic by her husband for a follow-up appointment. Two weeks ago, she was prescribed sertraline 50 mg daily for a 2-month history of pervasive sadness, sleeping 12 hours a day, a heavy sensation in her extremities, and a 10-lb weight gain following the sudden death of her father. Today, she reports no improvement in her mood and asks to stop the antidepressant because "two weeks is long enough to know it is not working."

She has a history of a pituitary microadenoma treated with transsphenoidal resection 3 years ago, for which she takes levothyroxine. She also takes a daily over-the-counter St. John's wort supplement. Upon further questioning, her husband notes that during college, the patient had a distinct 6-day period where she slept only 2 hours a night, spoke extremely rapidly, and maxed out her credit cards. She also mentions hearing her deceased father's voice calling her name once a few days ago.

Vital signs are within normal limits. Laboratory studies show:

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

A 24-year-old man is brought to the emergency department after sustaining a stab wound to the right upper quadrant of his abdomen during a physical altercation. On arrival, he appears confused, pale, and profusely diaphoretic. Vital signs are temperature 36.8°C (98.2°F), heart rate 138/min, blood pressure 75/40 mm Hg, and respiratory rate 22/min. Physical examination reveals a 3-cm linear laceration just below the right costal margin. The abdomen is notably distended with diffuse guarding and marked rebound tenderness in all four quadrants. Peripheral pulses are weak and thready. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old female software developer comes to the physician's office with her husband. She reports feeling profoundly sad and exhausted for the past month. The patient states she has no energy, sleeps up to 12 hours daily, and struggles to concentrate on her programming tasks. Two weeks ago, her primary care provider diagnosed her with major depressive disorder and prescribed fluoxetine. However, she states her mood has not improved and she now feels increasingly restless. During the interview, her husband notes that three years ago, the patient had a discrete 6-day period where she was unusually energetic, required only three hours of sleep per night, spoke very rapidly, and compulsively reorganized their entire home. She did not require hospitalization at that time and returned to her normal baseline afterward. Her past medical history is unremarkable. Vital signs are within normal limits. Laboratory studies reveal a serum thyroid-stimulating hormone (TSH) level of 1.8 µU/mL and a free T4 of 1.2 ng/dL. On mental status examination, she exhibits psychomotor retardation and a flat affect. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

A $52$-year-old man is brought to the emergency department by emergency medical services after being found somnolent in a park. He has a documented history of severe alcohol use disorder and has been unhoused for the past year. On initial evaluation, he is lethargic but easily rousable. Vital signs reveal a temperature of $35.8^\circ\text{C}$ ($96.4^\circ\text{F}$), blood pressure of $105/60\text{ mmHg}$, pulse of $112/\text{min}$, and respiratory rate of $14/\text{min}$. A point-of-care blood glucose level is $52\text{ mg/dL}$. Over the next hour, he becomes increasingly awake but is agitated, profoundly diaphoretic, and exhibits bilateral action tremors of his hands. Arrange the following clinical interventions in the most appropriate sequential order for the comprehensive management of this patient, from initial emergency presentation through hospital discharge.

A 28-year-old man is brought to the emergency department by his husband due to worsening fatigue, dizziness, and a recent syncopal episode. He is a competitive marathon runner who has been rigorously restricting his caloric intake for the past eight months to 'improve race times.' He reports an intense fear of gaining weight and strictly avoids any foods containing fat. Temperature is 35.4°C (95.7°F), blood pressure is 82/50 mm Hg, pulse is 38/min, and respirations are 12/min. BMI is 13.2 kg/m². Physical examination reveals temporal wasting, fine downy hair over his back, and cold, cyanotic extremities. Laboratory studies show:

An ECG reveals marked sinus bradycardia with a QTc interval of 490 ms. The patient is admitted to the hospital. Arrange the following multidisciplinary management steps in the most appropriate chronological order, from immediate acute intervention to long-term maintenance.

A 22-year-old man is brought to the emergency department by his college roommates after he began acting erratically and destroying furniture in their apartment. His roommates suspect he ingested a synthetic hallucinogen at a party earlier in the evening. In the evaluation room, the patient exhibits severe psychomotor agitation, rapid pacing, and hostility, loudly threatening to 'break out' of the hospital. He aggressively waves off the nurse who attempts to obtain vital signs.

Arrange the following interventions in the most appropriate sequential order for managing this patient's acute agitation, progressing from the least restrictive to the most restrictive measure.