All practice questions

A 17-year-old male is evaluated in the emergency department after experiencing a syncopal episode during cross-country track practice. He reports strictly limiting his food intake over the past 8 months to 'optimize his race times' and has subsequently lost 18 kg (40 lb). Temperature is 35.8°C (96.4°F), blood pressure is 80/50 mmHg, pulse is 38/min, and BMI is 13.5 kg/m². Physical examination reveals temporal wasting, lanugo on his back, and cold, cyanotic extremities. An electrocardiogram reveals marked sinus bradycardia with a prolonged QTc interval. Laboratory studies demonstrate significant hypokalemia, hypomagnesemia, and hypophosphatemia. Arrange the following interventions in the most appropriate chronological order for the comprehensive management of this patient, from the most immediate acute intervention to long-term follow-up.

A 24-year-old woman with a 3-year history of schizophrenia is admitted to the inpatient psychiatric unit. For the past four days, she has been entirely mute, refuses all food and fluids, and maintains rigid postures for hours. When the examiner attempts to reposition her arm, it remains exactly where placed. Her current medication is oral risperidone 4 mg daily, which her parents state she took consistently until three days ago. Her vital signs are within normal limits. Arrange the following management steps in the most appropriate chronological sequence for this patient's episode of care, assuming sequential escalation is required due to refractory symptoms before eventual resolution.

A 22-year-old man is brought to the clinic by his family and is subsequently diagnosed with schizophrenia. He has not received any previous psychiatric care. Arrange the following steps in the correct sequential order for the long-term psychopharmacologic management of this patient, starting with the initial therapy and progressing to the management of highly refractory disease.

A 45-year-old woman schedules an urgent clinic visit noting that her right breast has become significantly enlarged, heavy, and persistently red over the last three weeks. On physical examination, the right breast is diffusely erythematous and edematous, exhibiting prominent hair follicles resembling an orange peel. There is no discrete palpable mass, and her temperature is 37.1°C (98.8°F). Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the management of this patient's condition.

A 32-year-old woman presents to an outpatient addiction medicine clinic seeking treatment for severe opioid use disorder. She reports using intravenous heroin daily for the past 3 years and expresses a strong desire to stop. She is currently not intoxicated and shows no signs of opioid withdrawal, having last used heroin 2 hours ago. She and the physician agree to initiate buprenorphine/naloxone therapy. Arrange the following clinical steps in the correct chronological sequence required to safely and effectively initiate and maintain this pharmacotherapy.

A 45-year-old man presents to the clinic with a 6-week history of persistently depressed mood, profound anhedonia, terminal insomnia, 5-kg (11-lb) weight loss, and difficulty concentrating. He denies any suicidal ideation and exhibits no psychotic features. He has no prior psychiatric or medical history and is currently treatment-naive. Based on standard clinical guidelines, arrange the following management steps in the most appropriate chronological sequence for this patient. Assume that at each subsequent step, the patient experiences an inadequate clinical response despite adequate trial duration, documented medication adherence, and good tolerability.

A 38-year-old female presents to the clinic with an 8-week history of depressed mood, significant weight loss, early morning awakenings, and severe anhedonia, causing her to take a leave of absence from work. Over the subsequent 14 months, her clinical condition progresses through multiple phases of treatment resistance, eventually culminating in a psychiatric admission for active suicidal ideation with a specific plan. Arrange the following clinical actions in the correct chronological sequence according to evidence-based management guidelines for this patient's evolving condition, from her initial presentation through her eventual inpatient admission.

A 78-year-old man is hospitalized for community-acquired pneumonia. On the evening of hospital day 3, he becomes acutely confused, agitated, and combative towards nursing staff. He attempts to pull out his intravenous line, claiming that "snakes are biting his arm." His baseline cognitive function is intact. Arrange the following interventions for managing this patient's acute agitation in the correct escalating sequence, from the initial preferred approach to the absolute last resort.

A 19-year-old woman is admitted to the hospital with severe anorexia nervosa, restricting type. She presents with a BMI of 13.2 kg/m^2, a heart rate of 38/min, and a blood pressure of 82/50 mm Hg. The patient reports consuming only small amounts of water and black tea for the past two weeks. The multidisciplinary team is formulating a comprehensive treatment plan to ensure medical stabilization and long-term recovery while minimizing the risk of fatal complications. Arrange the following clinical management steps in the most appropriate sequential order, from immediate admission priorities to long-term management.

An adult patient with severe pelvic endometriosis is undergoing an elective total abdominal hysterectomy. While mobilizing the uterus from dense pelvic adhesions, sudden, bright red, pulsatile hemorrhage fills the deep pelvis, entirely obscuring the surgical field. The monitoring equipment alarms as the systolic blood pressure drops precipitously to 65 mm Hg. Arrange the following surgical and resuscitative interventions in the most appropriate sequential order to manage this acute life-threatening complication.

An 82-year-old retired pilot is currently admitted to the surgical ward on post-operative day three following an open reduction and internal fixation of a right femoral neck fracture. The on-call physician is paged urgently by the nursing staff because the patient has suddenly become highly disoriented, verbally aggressive, and is actively attempting to remove his peripheral intravenous catheter and surgical dressings. His baseline cognitive status prior to admission was completely intact.

Arrange the following clinical actions in the most appropriate sequential order for the evaluation and management of this patient's acute behavioral decompensation.

A 16-year-old girl is brought to the emergency department by her parents after she fainted during gymnastics practice. She has a 9-month history of severe dietary restriction and intense fear of gaining weight. Her current body mass index (BMI) is $13.2 \text{ kg/m}^2$. Vital signs show a temperature of $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), blood pressure of 82/50 mm Hg, and a heart rate of 34/min. Physical examination reveals diffuse muscle wasting, lanugo, and delayed capillary refill. Initial laboratory studies show:

An electrocardiogram (ECG) reveals sinus bradycardia with a QTcF of 510 ms.

Arrange the following management steps in the most appropriate chronological order to safely stabilize and treat this patient.

A 25-year-old woman is admitted to the inpatient psychiatric unit for an acute exacerbation of schizoaffective disorder. During the evening shift, she becomes increasingly distressed, claiming that the nursing station is broadcasting her thoughts. She begins throwing plastic cups across the hallway and screaming at the staff to stop the broadcast. She is hypervigilant, visibly tense, and standing defensively in the hallway corner, but she has not attacked anyone. Arrange the following interventions in the most appropriate stepwise escalation sequence for managing this patient's acute agitation, starting with the initial preferred step.

A 45-year-old woman presents to the clinic with a 6-month history of difficulty falling asleep and staying asleep. She states that her sleep problems began after a stressful period at work but have persisted despite the stress resolving. She reports daytime fatigue that is noticeably affecting her job performance. She has no other medical conditions and takes no medications. Arrange the following steps in the most appropriate chronological sequence for the standard clinical management of this patient's condition.

A $28$-year-old man is brought to the emergency department by his partner due to worsening lethargy and near-syncope. Over the past year, he has severely restricted his dietary intake and exercises intensely for $3$ hours daily, expressing a profound fear of gaining weight. Physical examination reveals temporal wasting and lanugo over his trunk. Temperature is $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), blood pressure is $82/50 \text{ mm Hg}$, pulse is $38\text{/min}$, and respirations are $12\text{/min}$. His body mass index is $12.4 \text{ kg/m}^2$. Electrocardiogram reveals sinus bradycardia with a prolonged QTc interval. Initial laboratory studies show:

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

A 74-year-old man with a 9-year history of Parkinson disease and emerging cognitive decline is brought to the emergency department by his daughter due to acute-onset, severe agitation and frightening visual hallucinations over the past 48 hours. He states that strangers are hiding in his room. His current medication regimen includes carbidopa-levodopa, pramipexole, and trihexyphenidyl. Arrange the following steps in the correct clinical escalation sequence for the evaluation and management of this patient's acute neuropsychiatric presentation, moving from initial assessment to therapies for refractory symptoms.

A 34-year-old male distance runner is brought to the hospital by his partner due to profound weakness and near-syncope. His body mass index is $13.5 \text{ kg/m}^2$, heart rate is $38/\text{min}$, and blood pressure is $82/50 \text{ mm Hg}$. He reports eating fewer than $500 \text{ kcal}$ daily for the past three months to 'improve race times'. He is admitted to the medical intensive care unit for severe anorexia nervosa. Arrange the following steps in the optimal sequence for managing this patient's acute and long-term care to minimize the risk of potentially fatal complications.

A 54-year-old man with a severe alcohol use disorder is brought to the emergency department by emergency medical services due to confusion and unsteadiness. He was found wandering in the street. His last alcoholic drink was approximately 24 hours ago. On presentation, he is diaphoretic, tachycardic (heart rate 118/min), and visibly tremulous. Neurologic examination reveals bilateral horizontal nystagmus, a wide-based ataxic gait, and profound global confusion. Point-of-care blood glucose testing shows 58 mg/dL (3.2 mmol/L). The patient is admitted to the hospital.

Arrange the following management steps in the most appropriate chronological sequence for this patient, from immediate acute stabilization to pre-discharge planning.

A 62-year-old woman undergoes a routine screening mammogram that reveals a new, highly suspicious 1.5-cm spiculated density with clustered microcalcifications in her left breast. She has no palpable masses or axillary lymphadenopathy on physical examination. Arrange the following interventions in the most appropriate chronological sequence for the evaluation and initial management of this patient's findings.

A primary care physician is evaluating a 71-year-old retired mechanic who is accompanied by his son. The son reports that over the past 14 months, his father has exhibited progressive short-term memory loss, missed several bill payments, and recently struggled to recall the names of his grandchildren. The patient feels he is "doing just fine" and is mildly annoyed by the visit. Vital signs are normal, and the neurological examination is nonfocal. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for evaluating and managing this patient's suspected major neurocognitive disorder, from initial clinical assessment to definitive management.