All practice questions

A 38-year-old male pedestrian is brought to the emergency department after being struck by a delivery truck at highway speeds. Upon arrival, he has agonal respirations. Physical examination reveals massive midfacial crush injuries with active oropharyngeal hemorrhage. His vital signs are temperature 35.5°C (95.9°F), blood pressure 68/35 mmHg, pulse 142/min, and respiratory rate 6/min. There are absent breath sounds over the right hemithorax and pronounced jugular venous distention. The pelvis is mechanically unstable on manual compression, and a rapidly expanding scrotal hematoma is noted. Based on Advanced Trauma Life Support (ATLS) protocols, arrange the following management steps in the most appropriate chronological order.

A psychiatric consult service is reviewing the charts of four newly evaluated patients who present with prominent depressive symptoms. Each patient's presentation requires a distinct pharmacological or procedural approach. Match each patient's clinical profile with the most appropriate next step in management or treatment strategy.

Eight hours following an open inguinal hernia repair under spinal anesthesia, a 55-year-old man reports lower abdominal discomfort and an inability to pass urine. His vital signs are stable. Physical examination demonstrates a palpable suprapubic mass with dullness to percussion. Arrange the following steps in the most appropriate chronological sequence for the management of this patient's postoperative complication.

Match each patient's clinical presentation with the most appropriate next step in management.

Match each classic thoracic trauma presentation with its most appropriate initial specific management step.

A 54-year-old woman presents to the emergency department with severe lower abdominal pain and a sensation of a "bulge" in her vagina. The symptoms started abruptly after an episode of severe coughing. She underwent a total laparoscopic hysterectomy for abnormal uterine bleeding 14 days ago. Her temperature is 37.2°C (99.0°F), blood pressure is 112/72 mm Hg, and pulse is 118/min. On pelvic examination, a 10-cm segment of small bowel is visible protruding through the vaginal introitus. The bowel appears pink and viable, but the patient is in significant distress.

Arrange the following management steps for this patient in the most appropriate chronological order.

A 65-year-old man is evaluated on postoperative day 6 following an elective open sigmoid colectomy for recurrent diverticulitis. Over the past 24 hours, he has developed a fever and increasing pain at his surgical incision site. His temperature is 38.5°C (101.3°F), blood pressure is 130/80 mm Hg, and pulse is 95/min. Examination of the abdomen reveals intact surgical staples, but there is a 4-cm area of erythema, induration, and warmth around the lower half of the incision. Gentle palpation of this area yields a small amount of purulent discharge. The remainder of his abdominal examination shows mild tenderness without rebound or guarding. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation of an antipsychotic-associated complication to the most appropriate next step in pharmacological or clinical management.

Match each of the following clinical presentations with the most likely underlying vascular pathology.

A 38-year-old male construction worker is brought to the emergency department after falling approximately 25 feet from a scaffold. On arrival, his blood pressure is 72/40 mmHg, heart rate is 138/min, and respiratory rate is 24/min. He is lethargic but maintaining his airway. Bilateral breath sounds are clear and equal. The abdomen is soft, non-distended, and lacks rebound tenderness or guarding. Gentle anteroposterior compression of the iliac crests reveals abnormal outward mobility of the pelvis. Intravenous access is established, and resuscitation with uncrossmatched blood is initiated. A bedside focused assessment with sonography for trauma (FAST) examination demonstrates no free fluid in the pericardial, hepatorenal, splenorenal, or rectovesical spaces. Which of the following is the most appropriate next step in management?

An emergency department physician evaluates a 29-year-old man who presents with a rapidly spreading, painful dermatologic eruption. The patient has a known psychiatric history of bipolar I disorder, for which he has been maintained on divalproex sodium for the past four years without any manic relapses. Six weeks ago, his outpatient psychiatrist prescribed an additional medication to address a severe, functionally impairing depressive episode. Upon physical examination, the patient's temperature is 39.2°C (102.6°F). There is a widespread, tender, purpuric maculopapular rash exhibiting epidermal detachment when lateral pressure is applied. Erosions are visible on the buccal mucosa and bilateral conjunctivae. Which of the following prescribing oversights is the most likely cause of this patient's current presentation?

A 22-year-old male college student is brought to the psychiatric emergency department by his parents due to severe depression. For the past four weeks, he has isolated himself in his room, slept up to 15 hours a day, eaten very little, and frequently expressed feelings of worthlessness. He admits to having passive thoughts of suicide but denies any active plan. Review of his medical record reveals a prior psychiatric hospitalization three months ago. During that admission, he presented with a 4-week history of sleeping only 2 hours per night, rapid and pressured speech, excessive spending, and experiencing auditory hallucinations of 'angels' telling him he was chosen for a divine mission. His symptoms resolved completely during that hospitalization with the temporary use of haloperidol, and he has not taken any medications since discharge. Vital signs are within normal limits, and the physical examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Paramedics arrive at the emergency department with a $24$-year-old male who was found severely agitated and disoriented outside a music festival. Bystanders reported seeing him consume a crystalline powder they believed to be "Molly" (MDMA) several hours prior. The patient's roommate, who accompanied him in the ambulance, notes that the patient has a history of major depressive disorder and recently began taking a daily medication prescribed through an online telehealth service.

Upon evaluation in the trauma bay, the patient is combative and profoundly confused. Vital signs demonstrate a temperature of $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), pulse of $142/\text{min}$, respiratory rate of $24/\text{min}$, and blood pressure of $175/105\text{ mm Hg}$. The physical examination is notable for excessive diaphoresis, bilateral pupillary dilation, and extreme muscle rigidity in the lower extremities accompanied by spontaneous ankle clonus.

Which of the following represents the most appropriate next step in patient care?

A 79-year-old hospitalized man with a history of mild vascular dementia develops acute-onset disorientation, visual hallucinations, and severe psychomotor agitation on his third evening following a laparoscopic cholecystectomy. He is shouting at the nursing staff, exhibiting a fluctuating level of consciousness, and repeatedly attempting to remove his peripheral intravenous catheter. Arrange the following management steps in the most appropriate clinical escalation sequence for treating this patient's acute behavioral disturbance.

A busy metropolitan emergency department evaluates four patients presenting with varying signs of acute substance intoxication or withdrawal. Match each patient's clinical presentation with the most likely corresponding toxidrome or substance-related state.

A 26-year-old woman is evaluated in the outpatient clinic for a two-month history of sudden, unpredictable episodes of overwhelming fear, palpitations, and a sensation of impending doom. These episodes reach their peak intensity within minutes and typically resolve after 15 to 20 minutes. Due to an intense fear of experiencing another episode in public, she has stopped using public transportation and avoids going to shopping malls. Her past psychiatric history is significant for a psychiatric hospitalization at age 21 for a severe manic episode involving grandiosity, rapid speech, and a decreased need for sleep. She was treated with a mood stabilizer at that time but discontinued the medication three years ago and has remained euthymic since. She also has a history of opioid use disorder and has been successfully maintained on buprenorphine-naloxone therapy for the past three years. Vital signs are within normal limits, and a recent comprehensive medical workup was unremarkable. Which of the following is the most appropriate next step in management?

A 48-year-old construction worker arrives at the emergency department via helicopter after being crushed by a steel beam across his hips. He is confused, pale, and diaphoretic. Vital signs demonstrate a heart rate of 138/min and a blood pressure of 72/40 mm Hg. His airway is patent and lungs are clear to auscultation bilaterally. Emergency medical personnel placed a circumferential pelvic sheet prior to transport. On evaluation, his abdomen is non-distended and soft to palpation. Inspection of the perineum reveals a scrotal hematoma and blood at the urethral meatus. Point-of-care ultrasound of the abdomen and pericardium shows no abnormal fluid collections. A portable chest radiograph is normal. Anteroposterior pelvic radiograph reveals an open-book pubic symphysis diastasis and a right sacroiliac joint disruption. Despite the rapid infusion of 2 units of uncrossmatched packed red blood cells, his blood pressure remains 75/42 mm Hg. Which of the following is the most appropriate next step in management?

A $45$-year-old man is evaluated on postoperative day $7$ following an emergent exploratory laparotomy and splenectomy for a grade IV splenic laceration sustained in a motor vehicle collision. For the past $48$ hours, he has reported new-onset left-sided pleuritic chest pain and persistent hiccups. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), heart rate is $112/\text{min}$, blood pressure is $118/74\text{ mm Hg}$, and respiratory rate is $20/\text{min}$. Pulse oximetry is $94\%$ on room air. Pulmonary examination reveals decreased breath sounds and dullness to percussion at the left lung base. Abdominal examination shows a well-healing midline incision and mild left upper quadrant tenderness without rebound or guarding. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$. A chest radiograph reveals an elevated left hemidiaphragm and a moderate left-sided pleural effusion with basilar linear opacities. Which of the following is the most appropriate next step in management?

A 42-year-old woman is brought to the emergency department 30 minutes after a high-speed motor vehicle collision in which she was the unrestrained driver. Upon arrival, her temperature is 36.5°C (97.7°F), blood pressure is 78/52 mmHg, pulse is 135/min, and respirations are 22/min. Her airway is patent and breath sounds are clear and equal bilaterally. Oxygen saturation is 97% on room air. The abdomen is severely distended with diffuse tenderness, guarding, and rebound tenderness. Two large-bore intravenous lines are established, and fluid resuscitation is initiated. A bedside focused assessment with sonography for trauma (FAST) reveals a significant amount of anechoic free fluid in the splenorenal and hepatorenal recesses. Which of the following is the most appropriate next step in management?

A 45-year-old woman is brought to the emergency department 30 minutes after being rescued from a residential fire. Her airway is patent, and she is hemodynamically stable. Physical examination reveals deep partial-thickness and full-thickness burns involving her entire anterior trunk, her entire right arm, and her entire right leg. Her estimated weight is $80 \text{ kg}$. Using the Parkland resuscitation formula ($4 \text{ mL/kg/} \% \text{TBSA}$), what should be the target rate of intravenous lactated Ringer solution administration, in $\text{mL/hour}$, for the first 8 hours following her injury?