All practice questions

A 59-year-old male with untreated hypertension arrives at the emergency department reporting the abrupt onset of a severe, tearing pain in his anterior chest that radiates straight to his interscapular region. His blood pressure is 210/115 mmHg, and his heart rate is 112/min. A portable chest radiograph demonstrates a widened mediastinum. Acute aortic dissection is highly suspected. Arrange the following clinical steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A 55-year-old woman is brought to the emergency department due to a 1-day history of severe left flank pain, shaking chills, and confusion. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $122/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals severe left costovertebral angle tenderness. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ with a left shift. A non-contrast computed tomography (CT) scan of the abdomen and pelvis reveals a 9-mm obstructing calculus in the proximal left ureter associated with moderate left hydroureteronephrosis and perinephric stranding. Arrange the following interventions in the most appropriate chronological order for the standard management of this patient.

During a routine health maintenance visit, a 54-year-old woman is found to have an elevated serum calcium level of $11.4 \text{ mg/dL}$ (normal: $8.4-10.2 \text{ mg/dL}$), with a normal serum albumin of $4.0 \text{ g/dL}$. She has a past medical history significant for an episode of nephrolithiasis two years ago. She currently takes amlodipine for mild hypertension. She denies bone pain, abdominal pain, or changes in mood. To appropriately manage this patient, arrange the following diagnostic and therapeutic steps into the correct chronological sequence.

A 55-year-old woman presents to the clinic after discovering a firm, painless lump in her right breast 2 weeks ago. Physical examination reveals a 2.5-cm hard, irregular, and relatively fixed mass in the upper outer quadrant of the right breast. There is no nipple discharge, skin dimpling, or palpable axillary lymphadenopathy. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient.

A 22-year-old male is transported to the trauma bay via helicopter following a high-speed motorcycle collision where he was ejected and found without a helmet. Upon arrival, his blood pressure is 165/95 mm Hg, and his heart rate is 55/min. He does not open his eyes to pain, makes incomprehensible sounds, and exhibits extension of his arms and legs in response to painful stimuli. Examination reveals a 6-mm, nonreactive right pupil and a 3-mm, briskly reactive left pupil.

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

A 65-year-old man is brought to the emergency department after experiencing three large episodes of painless, maroon-colored stool at home. He has a history of hypertension, hyperlipidemia, and osteoarthritis for which he takes naproxen daily. Upon arrival, he is lethargic. His temperature is 37.0°C (98.6°F), blood pressure is 85/50 mm Hg, and pulse is 122/min. Physical examination reveals pale conjunctivae and a non-tender, non-distended abdomen. Rectal examination shows gross maroon blood. Arrange the following interventions in the most appropriate chronological order for the optimal management of this patient, assuming the bleeding source remains elusive and persistent at each preceding diagnostic or therapeutic step.

A 68-year-old woman is brought to the emergency department by paramedics after a syncopal episode at a local grocery store. Upon awakening, she reports sudden, agonizing lower back pain and left flank pain. Her medical history includes hypertension, hyperlipidemia, and a 40-pack-year smoking history. Vital signs show a heart rate of 128/min, blood pressure of 72/48 mmHg, and respiratory rate of 22/min. Physical examination reveals a diaphoretic and pale patient. Her abdomen is distended, and a pulsatile, tender mass is palpated in the epigastrium. Two large-bore peripheral intravenous catheters are successfully placed by the trauma team. Arrange the following steps in the most appropriate sequential order for the management of this patient.

A $31$-year-old woman, currently at $12$ weeks gestation, is evaluated in the surgical oncology clinic for a new, firm, $4\text{ cm}$ mass in the upper outer quadrant of her right breast. Physical examination confirms the presence of a fixed, non-tender breast mass and a palpable, hard ipsilateral axillary lymph node. Assuming her final pathology ultimately reveals an estrogen receptor-positive, HER2-negative invasive ductal carcinoma, arrange the following steps in the most appropriate chronological sequence for her diagnostic workup and therapeutic management.

A 52-year-old man is admitted to the intensive care unit with severe acute gallstone pancreatitis. Over the past 48 hours, he has required aggressive intravenous crystalloid resuscitation for hemodynamic instability. He is mechanically ventilated. The nurse alerts the physician that the patient has become increasingly difficult to ventilate, with peak airway pressures rising from 25 to 45 cm H2O. Urine output over the last 4 hours is 30 mL. Physical examination reveals a tense, massively distended abdomen. Bladder pressure measurement reveals an intra-abdominal pressure (IAP) of 28 mmHg. Arrange the following management steps in the most appropriate sequential order, proceeding from initial, least-invasive measures to definitive interventions.

A $34$-year-old man is brought to the emergency department after a high-speed motorcycle collision. He has a heart rate of $122$/min and a blood pressure of $86/54$ mm Hg. Primary survey reveals an unstable pelvic ring fracture. Genitourinary examination demonstrates blood at the urethral meatus, a large scrotal hematoma, and a high-riding prostate on digital rectal examination. Arrange the following management steps in the optimal sequential order for this patient, proceeding from initial trauma resuscitation to definitive urologic repair.

Paramedics bring a 48-year-old previously healthy female to the emergency department. She reports the abrupt onset of an agonizing headache that began during heavy lifting, which she describes as the most severe pain she has ever experienced. She exhibits marked photophobia and neck stiffness on examination. Her vital signs are stable, and she is fully alert without lateralizing neurologic deficits. Arrange the following interventions in the most appropriate chronological sequence for her evaluation and definitive care, from initial presentation to post-treatment management.

A 26-year-old male is brought to the emergency department after a high-speed motorcycle collision. He sustained a severe posterior dislocation of his right knee and was trapped under the vehicle for 6 hours before extrication. On arrival, his blood pressure is 115/75 mm Hg and heart rate is 98/min. The right lower extremity is pale, cold, and lacks sensation. Dorsalis pedis and posterior tibial pulses are absent by palpation and Doppler ultrasound. The knee is immediately reduced in the emergency department, but the foot remains cold and pulseless. The patient is taken emergently to the operating room for limb-salvage surgery. Arrange the following operative steps in the most appropriate sequential order for managing this patient's combined injuries.

A 52-year-old man is brought to the emergency department by his wife due to the sudden onset of an excruciating headache and vomiting that began 2 hours ago. He also complains of blurry vision and difficulty seeing objects in his peripheral vision. His medical history is significant for decreased libido and profound fatigue over the last 6 months. On arrival, his blood pressure is 80/50 mmHg, and his heart rate is 118/min. Neurologic examination reveals a bitemporal hemianopsia. He appears lethargic but is oriented. Arrange the following steps in the most appropriate chronological order for the emergency evaluation and management of this patient:

A 41-year-old man presents with recurrent nephrolithiasis, episodic severe headaches, palpitations, and a 3-cm anterior neck mass. Laboratory evaluation shows a serum calcium of 11.6 mg/dL with an inappropriately elevated intact parathyroid hormone level. Fine-needle aspiration of the neck mass reveals malignant cells with amyloid stroma that stain positive for calcitonin. Genetic testing confirms a RET proto-oncogene mutation, establishing a diagnosis of Multiple Endocrine Neoplasia type 2A (MEN2A). The patient requires comprehensive surgical management. Arrange the following steps in the most appropriate chronological order for his evaluation and management:

A 58-year-old man arrives at the emergency center reporting sudden, severe, tearing chest discomfort that radiates directly between his scapulae. His blood pressure is 210/115 mmHg in the right arm and 170/90 mmHg in the left arm, with a pulse of 110/min. Physical examination reveals an early diastolic murmur at the right upper sternal border. An electrocardiogram shows no acute ischemic changes, and a portable chest radiograph demonstrates a widened mediastinum. Arrange the following management steps in the most appropriate chronological order.

A 29-year-old man with a history of sickle cell disease presents to the emergency department with a painful, rigid erection that has persisted for the last 8 hours without sexual stimulation. He has not responded to oral analgesics or warm compresses at home. Arrange the following steps in the correct chronological sequence for the standard step-wise management of this condition, starting with the initial diagnostic step and progressing through escalating medical and surgical interventions.

A 48-year-old female patient is brought to the emergency department experiencing high fever, rigors, and intense right-sided back pain. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), heart rate is $118/\text{min}$, and blood pressure is $88/56\text{ mm Hg}$. A noncontrast CT scan of the abdomen and pelvis demonstrates an $8\text{-mm}$ calculus in the proximal right ureter with associated moderate hydronephrosis. Arrange the following clinical steps in the most appropriate chronological sequence for managing this patient.

A 42-year-old man presents with a 10-day history of worsening headaches and new-onset mild right-hand clumsiness. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $128/82\text{ mm Hg}$, and pulse is $76\text{/min}$. He is fully awake, alert, and oriented with a Glasgow Coma Scale score of 15. Neurologic examination shows mild right upper extremity pronator drift but no other focal deficits. MRI of the brain with gadolinium reveals a single $3.2\text{ cm}$ centrally necrotic, ring-enhancing lesion in the left frontal lobe with moderate surrounding vasogenic edema and $3\text{ mm}$ of midline shift. There are no signs of impending brain herniation.

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

A 42-year-old man presents to the emergency department with a painful, rigid erection that has persisted for 10 hours. He denies any recent sexual activity or use of phosphodiesterase inhibitors, but reports a history of sickle cell trait. Penile blood gas analysis reveals a pO2 of 25 mmHg, pCO2 of 80 mmHg, and pH of 7.15, confirming the diagnosis of ischemic priapism. Non-invasive measures such as systemic analgesia and intravenous hydration have already been initiated.

Arrange the following stepwise interventions in the correct escalating order for managing this patient's condition.

A 25-year-old man is brought to the emergency department after a motorcycle collision. Examination reveals an obvious deformity of the right lower leg with a 4-centimeter laceration over the anterior tibia, exposing the underlying fractured bone. Distal pulses are palpable, and the patient has intact sensation in the foot. Arrange the following steps in the most appropriate chronological sequence for the acute management of this patient's open fracture.