All practice questions

A 74-year-old individual with a history of persistent atrial fibrillation and nonadherence to systemic anticoagulation is rushed to the operating room with sudden-onset, severe abdominal pain that is entirely out of proportion to physical examination findings. Laboratory studies reveal a profound lactic acidosis. A clinical diagnosis of acute superior mesenteric artery (SMA) embolism is made. Arrange the following intraoperative steps in the correct sequential order required to optimize the patient's surgical outcome and minimize the long-term risk of short bowel syndrome.

A $42$-year-old female patient arrives at the outpatient clinic reporting a $12$-month history of unexplained weight gain, severe fatigue, and frequent bruising. Her blood pressure is $155/95\text{ mm Hg}$. Physical examination is notable for central adiposity, facial plethora, and wide, purplish striae on the lower abdomen. She denies taking any medications, including topical, inhaled, or intra-articular corticosteroids. The physician suspects an endogenous endocrine disorder. Arrange the following interventions in the most appropriate chronological sequence for the diagnosis and surgical management of this patient's condition.

A 28-year-old man is brought to the trauma center following a high-speed motorcycle collision. His airway is intact, and his hemodynamics are stabilized with intravenous fluids. A pelvic binder is applied for a complex pelvic ring fracture. Physical examination reveals a scrotal hematoma and fresh blood at the urethral meatus. Digital rectal examination demonstrates a high-riding, nonpalpable prostate. He reports lower abdominal discomfort and a strong urge to void, but has not urinated since the accident. Arrange the following urologic interventions in the most appropriate chronological order for the evaluation and definitive management of this patient's genitourinary injury.

A $44$-year-old woman is evaluated on postoperative day $3$ following a complicated total abdominal hysterectomy for severe endometriosis. She reports new-onset right-sided flank pain and nausea. Her temperature is $38.2^{\circ}\text{C}$ ($100.8^{\circ}\text{F}$). Physical examination reveals right costovertebral angle tenderness. The pelvic surgical drain has abruptly started outputting a high volume of clear, watery fluid. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for managing this patient's suspected urologic complication.

A 24-year-old man is brought to the emergency department via ambulance after diving into a shallow lake and striking his head on the bottom. He is conscious but reports an inability to move his arms or legs. His blood pressure is 78/40 mm Hg, heart rate is 52/min, and respiratory rate is 22/min. Oxygen saturation is 94% on room air. He has flaccid paralysis and absent reflexes in all four extremities. Arrange the following steps in the optimal sequence for the management of this patient, from initial presentation to definitive treatment.

An unrestrained 24-year-old male driver is transported to the emergency department following a severe front-end motor vehicle collision. Primary survey reveals a hemodynamically stable patient with an isolated right lower extremity injury. The right leg is visibly shortened, adducted, and internally rotated. The patient complains of intense right hip pain and an inability to feel the top of his right foot. Subsequent imaging during his care reveals an incongruent joint space requiring definitive operative intervention. Arrange the following steps in the correct chronological order for the optimal, evidence-based management of this patient's injury.

A 32-year-old female arrives at the emergency department via ambulance following a high-speed motorcycle collision. She has an obvious deformity of her right lower leg with a 5-centimeter laceration over the anterior tibia exposing the underlying bone. Active oozing of blood is noted. Her pulse is 110/min, and blood pressure is 115/75 mm Hg. Arrange the following initial management steps in the most appropriate chronological sequence for this patient.

A 45-year-old woman is brought to the emergency department by her partner after developing a sudden-onset, excruciating headache that she describes as the 'worst of my life.' The headache began abruptly 2 hours ago while she was moving heavy furniture. She reports associated nausea, photophobia, and neck stiffness. Her temperature is 37.2°C (99.0°F), blood pressure is 168/94 mm Hg, and heart rate is 92/min. Neurological examination reveals intact cranial nerves, normal symmetric strength, and marked nuchal rigidity. Arrange the following steps in the correct sequential order for the standard diagnostic workup and definitive management of this patient, assuming the initial head imaging does not demonstrate an acute hemorrhage.

A 72-year-old man is brought to the emergency department by emergency medical services due to the sudden onset of massive, painless hematochezia that began 2 hours ago. His past medical history includes hypertension, hyperlipidemia, and coronary artery disease. On arrival, he is pale and diaphoretic. His temperature is 37.1°C (98.8°F), heart rate is 132/min, blood pressure is 82/50 mmHg, and respiratory rate is 22/min. Physical examination reveals a soft, non-tender, and non-distended abdomen. Digital rectal examination demonstrates gross bright red blood without palpable masses. Initial laboratory studies show a hemoglobin of 7.8 g/dL (baseline 13.5 g/dL), blood urea nitrogen (BUN) of 42 mg/dL, and serum creatinine of 1.1 mg/dL.

Arrange the following interventions in the most appropriate sequential order for the optimal algorithmic management of this patient's acute presentation.

A 75-year-old woman with a history of heart failure and atrial fibrillation is brought to the emergency department due to the sudden onset of severe, diffuse abdominal pain. She reports nausea and one episode of non-bloody emesis. Her temperature is 37.8°C (100.0°F), blood pressure is 135/85 mmHg, pulse is 115/min and irregularly irregular, and respiratory rate is 18/min. On physical examination, her abdomen is soft, non-distended, and mildly tender to deep palpation, without rebound tenderness or guarding. Bowel sounds are decreased. Laboratory studies reveal a leukocyte count of 18,000/mm³ and a serum lactate level of 4.5 mmol/L. Arrange the following steps in the most appropriate chronological sequence for the definitive management of this patient.

A 35-year-old man is evaluated in the surgical oncology clinic after a painless neck mass was discovered during a routine physical examination. Ultrasound of the neck reveals a 2.5-cm solid, hypoechoic nodule in the right thyroid lobe. Subsequent fine-needle aspiration biopsy of the nodule demonstrates sheets of polygonal cells in an amyloid stroma, confirming medullary thyroid carcinoma. During the interview, the patient reports a 6-month history of episodic severe headaches, profuse sweating, and palpitations. His vital signs show a blood pressure of 168/98 mmHg and a heart rate of 110/min. His family history is notable for a father who died of a hypertensive stroke at age 45. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for this patient's management.

A 54-year-old woman is brought to the emergency department for severe right flank pain, nausea, and chills over the past 24 hours. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $86/52 \text{ mmHg}$, pulse is $122/\text{min}$, and respirations are $22/\text{min}$. Physical examination demonstrates marked right costovertebral angle tenderness. Laboratory studies reveal a leukocyte count of $19,500/\text{mm}^3$ and a serum creatinine of $1.8 \text{ mg/dL}$. A non-contrast computed tomography scan of the abdomen and pelvis demonstrates an $8\text{-mm}$ calculus in the proximal right ureter with associated moderate hydronephrosis and perinephric fat stranding. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 42-year-old man is brought to the emergency department after a high-speed head-on motor vehicle collision. He complains of severe chest and mid-back pain. His blood pressure is 165/90 mm Hg, pulse is 112/min, and respirations are 22/min. Oxygen saturation is 96% on room air. The primary survey is complete; his airway is patent, and breath sounds are equal bilaterally. There is a visible seatbelt sign across his chest. Arrange the following steps in the most appropriate chronological sequence for diagnosing and managing this patient's suspected blunt thoracic aortic injury.

A 25-year-old woman presents for a routine well-woman examination. Arrange the following steps in the correct chronological order for the appropriate cervical cancer screening and subsequent clinical management of this patient according to current guidelines.

A 24-year-old man is evaluated in the hospital 12 hours after sustaining a closed, comminuted midshaft fracture of the right tibia. The fracture was stabilized with a well-molded, long-leg fiberglass cast in the emergency department. He now reports severe, unrelenting right leg pain that is poorly localized and unresponsive to intravenous opioid analgesia. Physical examination reveals a tense, swollen right calf and severe pain exacerbated by passive dorsiflexion of the right toes. Dorsalis pedis and posterior tibial pulses are easily palpable. Arrange the following management steps in the most appropriate chronological order.

Emergency medical services transport a logging worker via helicopter to a regional trauma center after a heavy falling tree branch crushed his right lower extremity. The patient remains hemodynamically stable throughout transport. Upon initial trauma evaluation, the right knee exhibits a gross multi-ligamentous dislocation with severe instability. Vascular assessment reveals a pale, cold right foot with no palpable or Doppler-identifiable pulses in the dorsalis pedis or posterior tibial arteries. Because of the remote location of the accident, the estimated total warm ischemia time has already exceeded 5.5 hours. An urgent bedside closed reduction is performed, but subsequent Doppler re-evaluation confirms persistent absence of arterial flow. The surgical team immediately mobilizes to the operating suite for a limb salvage procedure. Arrange the following intraoperative interventions in the correct sequential order required to optimize limb preservation.

A 32-year-old man presents to the emergency department with a severe, painful erection that has persisted for 8 hours without sexual stimulation. He has a history of sickle cell trait. On examination, the corpora cavernosa are extremely rigid and tender, while the glans penis and corpus spongiosum are flaccid. Arrange the following steps in the optimal sequential management of this patient's condition, from the initial diagnostic step to the progressive therapeutic interventions.

A 26-year-old professional rugby player is transported to the trauma bay after sustaining a direct, high-velocity blow to his right knee during a match. He complains of excruciating leg pain. On physical examination, the right knee is visibly deformed. His right foot is pale and cool to the touch. He is hemodynamically stable and has no other systemic injuries. Arrange the following steps in the acute management of this patient's limb in the most appropriate chronological sequence.

A 68-year-old woman with a history of type 2 diabetes mellitus and a 30-pack-year smoking history presents to the clinic complaining of cramping pain in her left calf. She reports that the pain consistently occurs after walking two blocks and resolves entirely after five minutes of standing still. She denies any pain at rest or non-healing foot ulcers. On physical examination, her femoral pulses are $2+$ bilaterally, but her left popliteal and dorsalis pedis pulses are diminished ($1+$). Arrange the following steps in the most appropriate chronological sequence for the standard diagnostic and therapeutic management of this patient's condition.

A $28$-year-old man is brought to the emergency department by ambulance after a high-speed motorcycle collision. He was not wearing a helmet. On arrival, he is unresponsive. His blood pressure is $175/95 \text{ mmHg}$, heart rate is $52 \text{ /min}$, and respiratory rate is $10 \text{ /min}$ and irregular. Neurologic examination reveals a Glasgow Coma Scale score of $5$ (Eye opening: $1$, Verbal response: $1$, Motor response: $3$). His right pupil is $7 \text{ mm}$ and unreactive to light, while the left pupil is $3 \text{ mm}$ and briskly reactive. He exhibits decerebrate posturing on the left side. Arrange the following steps in the most appropriate chronological order for the management of this patient.