All practice questions

Emergency medical services bring a $69$-year-old man to the trauma bay after he experienced a sudden, agonizing tearing pain in his mid-abdomen that radiates to his lower back. He has a $45$-pack-year smoking history and a history of poorly controlled hypertension. Upon arrival, the patient is obtunded, pale, and diaphoretic. His vital signs show a temperature of $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), a blood pressure of $72/40\text{ mm Hg}$, and a regular heart rate of $124/\text{min}$. Abdominal examination reveals a prominent, expansile, and pulsatile mass extending just above the umbilicus. Arrange the following diagnostic and therapeutic interventions in the most appropriate chronological sequence for the standard management of this patient.

A 14-year-old boy with a BMI of $31 \text{ kg/m}^2$ is brought to the clinic by his mother due to a 3-week history of right knee pain and a progressive limp. He denies any recent trauma, fever, or weight loss. Vital signs are within normal limits. On physical examination, there is no effusion, erythema, or tenderness to palpation over the right knee. Ligamentous testing of the right knee is intact. When the patient's right hip is passively flexed to $90^\circ$, the right thigh obligatorily rotates externally. Internal rotation of the right hip is significantly limited and elicits pain. Which of the following is the most appropriate next step in management?

A $72$-year-old man is evaluated on postoperative day $3$ following a total hip arthroplasty due to progressive, painless abdominal distension. He has not passed flatus or stool for $48$ hours. He is currently receiving intravenous morphine for pain. Vital signs are within normal limits. Physical examination reveals a massively distended, tympanitic abdomen with high-pitched bowel sounds, but no focal tenderness, guarding, or rigidity. An abdominal radiograph demonstrates diffuse dilation of the entire colon, with a cecal diameter of $10.5$ cm, but no evidence of a mechanical transition point or pneumoperitoneum. Assuming the patient's condition fails to improve with each successive treatment modality and there are no specific contraindications, arrange the following management steps in the correct sequential order according to standard treatment algorithms for acute colonic pseudo-obstruction (Ogilvie syndrome).

A 52-year-old male with a history of poorly controlled type 2 diabetes mellitus presents to the emergency department with a 2-day history of severe right knee pain, swelling, and subjective fevers. His temperature is $38.9^\circ\text{C}$ ($102^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, heart rate is $110/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals a markedly swollen, erythematous, and warm right knee. The patient refuses to bear weight, and there is exquisite pain with even minimal passive range of motion. Blood cultures are drawn in the emergency department.

Arrange the following next steps in the most appropriate sequential order for the acute management of this patient.

A 65-year-old woman is evaluated in the cardiovascular intensive care unit on postoperative day 4 following a coronary artery bypass grafting (CABG) procedure. Over the past 45 minutes, she has become increasingly restless, confused, and short of breath. Her temperature is 37.8°C (100.0°F), blood pressure is 82/50 mmHg, pulse is 122/min, and respirations are 26/min. On physical examination, her jugular veins are distended to the angle of the mandible while she is seated upright. Auscultation of the chest reveals clear lung fields bilaterally, but heart sounds are distant and muffled. Her extremities are cool and clammy, with a capillary refill time of 4 seconds. The sternal incision is intact without erythema or purulent discharge. Electrocardiography demonstrates sinus tachycardia with low-voltage QRS complexes. Which of the following is the most appropriate next step in the management of this patient?

Match each brief clinical presentation of a hepatobiliary disorder to its most specific diagnostic laboratory or imaging finding.

Match the following primary bone lesions with their most characteristic clinical presentation and radiographic features.

Correlate each of the following lower extremity vascular assessment findings with their most likely underlying surgical or vascular pathology.

A 34-year-old man is brought to the emergency department after a high-speed motorcycle collision. He was found 30 feet from his motorcycle and was unresponsive at the scene. Upon arrival, his temperature is 36.5°C (97.7°F), blood pressure is 76/40 mm Hg, pulse is 138/min, and respiratory rate is 28/min. He is immediately intubated for airway protection. A focused assessment with sonography for trauma (FAST) examination shows no intraperitoneal or pericardial fluid. The pelvis is mechanically stable to anteroposterior and lateral compression. A supine anteroposterior chest radiograph reveals a widened mediastinum, obliteration of the aortic knob, and depression of the left mainstem bronchus. Despite the rapid intravenous infusion of 2 liters of warmed crystalloid and 2 units of type O-negative packed red blood cells, his blood pressure remains 78/42 mm Hg. Which of the following is the most appropriate next step in management?

A 42-year-old man is brought to the emergency department following a high-speed motor vehicle collision. He was the restrained driver. Upon arrival, he is confused and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 78/50 mm Hg, pulse is 132/min, and respiratory rate is 24/min. Pulse oximetry shows 97% on room air. The airway is patent, and breath sounds are clear and equal bilaterally. A focused assessment with sonography for trauma (FAST) examination reveals no free fluid in the peritoneal cavity or pericardial sac. Physical examination demonstrates marked ecchymosis over the lower abdomen and perineum, with severe instability of the pelvic ring on gentle anteroposterior compression. There is blood at the urethral meatus. Bilateral lower extremity pulses are palpable but weak. Motor and sensory examinations of the lower extremities are limited due to patient confusion, but there are no gross deformities of the legs. Two large-bore intravenous lines are placed, and fluid resuscitation with isotonic crystalloid is initiated. Which of the following is the most appropriate next step in management?

A 64-year-old woman comes to the emergency department complaining of severe difficulty breathing that has progressively worsened over the last 72 hours. She also reports a persistent nighttime cough and states she must prop herself up with three pillows to sleep without feeling like she is suffocating. Her medical history includes hypertension, type 2 diabetes mellitus, and a 35-pack-year smoking history. Her temperature is 37.1°C (98.8°F), blood pressure is 162/94 mmHg, pulse is 108/min, and respirations are 24/min. Oxygen saturation is 92% on room air. Physical examination reveals distended neck veins when sitting at a 45-degree angle. Auscultation of the lungs demonstrates bibasilar crackles without wheezing. Cardiac auscultation reveals a regular rhythm, tachycardia, and a prominent S3 gallop. Examination of the lower extremities shows bilateral 2+ pitting edema extending to the mid-calves. Which of the following is the most appropriate initial pharmacological intervention for this patient?

Paramedics transport a male patient in his early forties to the trauma center following an industrial accident involving a crushed left lower extremity. Upon arrival, the patient exhibits altered sensorium and profound diaphoresis. Vital signs show a heart rate of 132 beats/min and a blood pressure reading of 78/42 mmHg. Physical assessment highlights a rapidly enlarging, pulsatile swelling in the medial aspect of the left thigh. The ipsilateral foot is pallid, cold, and lacks palpable or Doppler-identifiable pulses. Two large-bore peripheral venous catheters are placed, and fluid resuscitation begins. What is the most critical intervention to perform next for this individual?

A $65$-year-old woman is evaluated on postoperative day $7$ following a right total knee arthroplasty for severe osteoarthritis. She reports sudden, severe pain in the right knee that began yesterday and has progressively worsened. The patient has been compliant with prophylactic apixaban and routine postoperative physical therapy. Her temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $130/80$ mmHg, pulse is $102$/min, and respirations are $16$/min. Physical examination reveals a right knee that is significantly swollen, erythematous, and warm to the touch. The surgical incision is closed and intact without any frank purulent drainage, but there is marked tenderness over the joint capsule. Passive range of motion is extremely limited due to severe pain. Laboratory studies show a leukocyte count of $14,000/\text{mm}^3$ and an erythrocyte sedimentation rate of $85\text{ mm/h}$. Which of the following is the most appropriate next step in management?

A 62-year-old man presents to the emergency department with sudden-onset, severe, tearing anterior chest pain that radiates to his back. His blood pressure is 185/110 mm Hg and heart rate is 112/min. Physical examination reveals a new early diastolic murmur at the right sternal border and a noticeable difference in pulse amplitude between the right and left radial arteries. An acute type A aortic dissection is highly suspected. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 24-year-old university student presents to the outpatient clinic reporting persistent right wrist pain. Approximately 24 hours ago, he fell forward while skateboarding and braced his impact with an outstretched right hand. He describes a constant, dull ache located near the base of his thumb. On physical examination, there is minimal visible swelling and no obvious deformity. Palpation reveals distinct tenderness in the triangular depression on the radial aspect of the wrist when the thumb is fully extended. Capillary refill is less than 2 seconds, and sensation is intact in all digits. Initial anteroposterior, lateral, and scaphoid-view radiographs of the right wrist show no evidence of acute fracture, cortical disruption, or dislocation. Based on these findings, which of the following is the most appropriate next step in patient management?

A 78-year-old woman is brought to the emergency department after slipping and falling in her kitchen. She complains of severe left groin pain and is unable to bear weight on her left leg. She has a medical history of hypertension, type 2 diabetes mellitus, and osteoporosis. Vital signs are temperature 37.1°C (98.8°F), heart rate 82/min, blood pressure 138/86 mm Hg, and respiratory rate 16/min. Physical examination reveals normal alignment of the left lower extremity with no shortening or external rotation. However, severe pain is elicited with active straight leg raise and gentle internal rotation of the left hip. The dorsalis pedis and posterior tibial pulses are 2+ and symmetric. Sensation is intact to light touch in all distal dermatomes. Anteroposterior and cross-table lateral radiographs of the left hip and pelvis show severe osteopenia and degenerative joint disease but no cortical step-off or radiolucent fracture lines. Which of the following is the most appropriate next step in management?

A 52-year-old male is transported to the emergency department following an episode where he coughed up approximately 600 mL of bright red blood at home. He has a remote history of treated pulmonary tuberculosis. Upon arrival, the patient is actively coughing up additional large volumes of blood and appears in significant respiratory distress. Vital signs show a blood pressure of 105/65 mmHg, heart rate of 118/min, respiratory rate of 26/min, and oxygen saturation of 88% on room air. Chest auscultation demonstrates coarse crackles and absent breath sounds strictly over the right hemithorax; the left hemithorax is completely clear.

Arrange the following interventions for this patient in the most appropriate sequential order, proceeding from immediate bedside management to definitive care.

Match each clinical presentation following a recent acute myocardial infarction (left) with its precise underlying pathophysiologic mechanism and anatomical basis (right).

A 28-year-old woman is brought to the emergency department by her roommate due to severe agitation, confusion, and palpitations. She has a history of Graves disease but stopped taking her medications three months ago. Temperature is 40.2°C (104.4°F), blood pressure is 160/90 mm Hg, pulse is 150/min and irregular, and respirations are 24/min. Physical examination reveals a diffuse goiter, bilateral exophthalmos, fine tremor, and diaphoresis. An electrocardiogram shows atrial fibrillation with rapid ventricular response. A clinical diagnosis of thyroid storm is made. Arrange the following therapeutic interventions in the most appropriate chronological order for the management of this patient, from the most immediate acute step to long-term definitive therapy.

Emergency medical services bring a $74$-year-old woman to the acute care center due to a sudden deterioration in her clinical status. She resides in an assisted living facility and has a surgical history significant for multiple open pelvic operations. Caregivers report that she began experiencing intermittent, crampy abdominal discomfort two days ago, which abruptly transitioned into unrelenting, severe diffuse pain over the last three hours. Upon arrival, she is lethargic. Vital signs reveal a temperature of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), a heart rate of $128/\text{min}$, and a blood pressure of $82/48\text{ mm Hg}$. Physical assessment reveals a significantly distended abdomen with marked involuntary guarding and rebound tenderness in all four quadrants. Auscultation reveals absent bowel sounds. A point-of-care abdominal radiograph demonstrates markedly dilated small bowel loops and an absence of distal colonic gas. Which of the following is the most appropriate next step in management?