All practice questions

A 24-year-old woman is evaluated in the outpatient psychiatry clinic. She reports a 4-week history of severe sadness, loss of interest in her usual activities, hypersomnia, and low energy. She is diagnosed with major depressive disorder and prescribed escitalopram. The physician counsels her extensively on what to expect during the course of her treatment. Arrange the following clinical events in the typical chronological order of their occurrence after initiating this pharmacotherapy, from earliest to latest.

A 16-year-old girl is hospitalized for severe malnutrition secondary to anorexia nervosa, restricting subtype. Her body mass index (BMI) is $13.2 \text{ kg/m}^2$. The medical team plans to initiate careful nutritional rehabilitation but is acutely concerned about a potentially fatal metabolic complication characterized by severe electrolyte derangements. Arrange the following pathophysiological steps of this syndrome in the correct chronological sequence, starting from the initial dietary trigger to the ultimate clinical manifestations.

During surgical rounds, an attending physician is reviewing the classic timeline of postoperative complications with the medical team to establish a diagnostic protocol. Arrange the following common causes of postoperative fever in the correct chronological order of their typical onset, starting with the earliest expected complication and ending with the latest.

A 32-year-old man with a recent diagnosis of schizophrenia is admitted to the inpatient psychiatric unit due to worsening paranoia and command auditory hallucinations. Due to severe agitation, he is treated with multiple doses of intramuscular haloperidol over a 48-hour period. On hospital day 3, the patient develops profound "lead-pipe" muscle rigidity, a temperature of 39.4°C (102.9°F), profuse diaphoresis, and mutism. His blood pressure fluctuates between 160/100 mmHg and 90/60 mmHg, and his pulse is 122/min. Laboratory testing reveals a serum creatine kinase level of 4,500 U/L.

Arrange the following steps in the most appropriate chronological order for the acute management and subsequent follow-up of this patient's condition.

An 80-year-old man, a former university professor, visits his outpatient provider accompanied by his daughter. She expresses concern that over the past 18 months, he has been repeatedly misplacing important documents, forgetting appointments, and struggling to manage his finances. Last week, he was found wandering several blocks from his house, unable to remember the route back. Vital signs are stable, and the neurological examination shows no focal deficits. The provider plans a comprehensive evaluation and anticipates a long-term management strategy for presumed Alzheimer disease.

Arrange the following clinical steps in the appropriate chronological sequence for the standard diagnostic evaluation and progressive longitudinal management of this patient's condition.

A 62-year-old man with a long-standing history of severe, untreated schizophrenia is evaluated in the emergency department for a gangrenous right foot. The surgical team recommends an urgent below-the-knee amputation to prevent systemic sepsis, which carries a high risk of mortality if left untreated. The patient refuses the procedure, stating, "The aliens are using this foot as a transmitter; if you cut it off, they will destroy the hospital." His vital signs are stable, but he requires surgical intervention within the next 24 hours to prevent deterioration. Arrange the following steps in the most appropriate legal and ethical sequence to navigate this patient's refusal of life-saving care.

A 28-year-old man with a recent diagnosis of schizophrenia is started on haloperidol. His physician is reviewing the adverse effect profile with the patient and his family. Arrange the following extrapyramidal symptoms associated with high-potency typical antipsychotics in chronological order of their characteristic onset, from earliest to latest.

A 28-year-old man is currently hospitalized on an inpatient psychiatric unit for an acute exacerbation of bipolar I disorder, current episode manic. Over the past hour, he has become increasingly irritable, pacing the hallways rapidly. Suddenly, he begins shouting profanities, claims the nursing staff are 'demons trying to harvest his organs,' and hurls a metal trash can at the nurses' station wall, shattering a plastic clock. He clenches his fists and takes an aggressive combat stance toward an approaching psychiatric technician. Arrange the following interventions in the most appropriate sequence of escalation for managing this patient's acute agitation, according to standard psychiatric emergency protocols.

A 54-year-old postmenopausal woman presents to the physician's office after discovering a firm lump in her left breast three weeks ago. The patient has no history of breast trauma, nipple discharge, or skin dimpling. She experienced natural menopause at age 51. Her maternal aunt was diagnosed with breast cancer at age 68. Vital signs are within normal limits. Physical examination reveals a 2.5-cm, hard, irregular, and immobile mass in the upper outer quadrant of the left breast. There are no overlying skin changes, and no axillary or supraclavicular lymphadenopathy is appreciated.

Assume that subsequent evaluation confirms early-stage, estrogen receptor-positive, HER2-negative invasive ductal carcinoma, and the patient opts for breast-conserving management.

Arrange the following diagnostic and therapeutic steps in the most appropriate chronological order for this patient.

Law enforcement officers transport an unidentified young male to the emergency department. He was apprehended while running through a busy intersection, violently striking passing vehicles, and screaming about extraterrestrial entities. In the resuscitation bay, he exhibits extreme combativeness, vertical nystagmus, profuse diaphoresis, and flushed skin. Vital signs reveal a heart rate of $152$/min, blood pressure of $188/112$ mm Hg, and a core temperature of $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$). The patient requires physical restraint by multiple staff members to prevent immediate harm to himself and others.

Arrange the following clinical interventions in the most appropriate chronological order for managing this patient's acute presentation and subsequent care.

An 82-year-old man with a history of mild Alzheimer dementia is hospitalized for a urinary tract infection. On hospital day 2, he becomes acutely agitated, disoriented, and begins pulling at his intravenous lines. He is experiencing visual hallucinations and yelling at the nursing staff. Arrange the following interventions in the most appropriate sequential order of escalation, from initial best practices to interventions of absolute last resort, for the management of this patient's acute delirium with severe agitation.

Evaluated in the sleep clinic is a young adult university student reporting a two-year history of debilitating daytime hypersomnolence. The patient frequently falls asleep during interactive seminars despite maintaining a self-reported 8-hour nightly sleep schedule. In addition, the patient describes recent episodes where hearing a funny joke causes transient buckling of the knees and jaw drooping, with preserved consciousness throughout the event. Suspecting a specific central disorder of hypersomnolence, the clinician plans a comprehensive evaluation and treatment strategy. Arrange the following diagnostic and therapeutic steps in the most appropriate, guideline-directed chronological sequence for the management of this patient.

Paramedics bring a 27-year-old man to the emergency department after he was found unresponsive in an alley. On arrival, his blood pressure is 105/65 mmHg, pulse is 55/min, and respiratory rate is 5/min. Oxygen saturation is 78% on room air. Physical examination reveals pinpoint pupils and cyanosis of the lips. The patient is accompanied by his brother, who reports that the patient has struggled with prescription opioid misuse for years and recently transitioned to injecting street drugs. Following initial acute stabilization, the patient regains consciousness, becomes tearful, and strongly requests to start medication-assisted treatment for his addiction today. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 45-year-old woman is undergoing a complex total abdominal hysterectomy for severe, treatment-resistant endometriosis. During the dissection of the left infundibulopelvic ligament, the surgeon uses electrocautery to control unexpected bleeding near the pelvic sidewall. Shortly after, there is high clinical suspicion for a thermal injury to the left ureter. Arrange the following intraoperative steps in the most appropriate chronological order to evaluate and definitively manage this suspected complication.

A 41-year-old man presents to the clinic with persistent low mood, anhedonia, and insomnia that have significantly impaired his ability to perform his job. He is diagnosed with major depressive disorder (MDD). He has no prior psychiatric history, no history of hypomanic or manic episodes, and no acute suicidal ideation. He expresses a preference for pharmacological treatment. Assuming the patient experiences inadequate clinical improvement at each successive stage of treatment, arrange the following management steps in the correct chronological sequence according to standard stepped-care guidelines for MDD.

A 28-year-old male is brought to the emergency department immediately after a high-speed motor vehicle collision. He is visibly distressed, tachycardic, and has multiple contusions on his chest and abdomen. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial assessment and management steps in the correct chronological order.

Paramedics bring a 21-year-old university student to the emergency department following a syncopal episode during a ballet class. Her dance instructor notes she has appeared increasingly emaciated over the past six months and frequently complains of being cold. Upon arrival, the patient expresses intense fear of gaining weight despite her visible cachexia. Vital signs show a temperature of 35.6°C (96.1°F), blood pressure of 82/50 mm Hg, heart rate of 38/min, and respiratory rate of 12/min. Her body mass index is calculated at 12.8 kg/m2. Physical assessment reveals lanugo over her back and acrocyanosis. A 12-lead electrocardiogram demonstrates marked sinus bradycardia with a prolonged QTc interval. Laboratory evaluation highlights a serum potassium of 2.9 mEq/L and a serum phosphorus of 2.2 mg/dL. Arrange the following clinical management steps in the most appropriate chronological order from initial acute presentation to long-term maintenance.

While on call for the surgical ward, you are urgently called to the bedside of a patient who underwent an open exploratory laparotomy six days ago. The patient had a severe coughing fit and reported feeling a sudden 'popping' sensation in the abdomen. On examination, the surgical dressing is saturated with serosanguinous fluid. When you carefully lift the dressing, you observe that the fascial layer has separated and loops of small intestine are protruding onto the abdominal wall. Arrange the following immediate management steps in the most appropriate chronological order.

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.

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.