All practice questions

Match each clinical presentation following severe thoracic trauma to its most likely diagnosis.

For each patient presentation described in the surgical emergency and critical care setting below, select the most appropriate primary intervention from the available list.

A $54$-year-old male with known decompensated cirrhosis is brought to the emergency room after experiencing two episodes of large-volume, bright red hematemesis at home. Upon arrival, he is pale and lethargic but is able to converse and is protecting his airway. Vital signs reveal a blood pressure of $88/56$ mm Hg, heart rate of $118$/min, respiratory rate of $18$/min, and oxygen saturation of $96\%$ on ambient air. Physical examination demonstrates scleral icterus, caput medusae, and shifting dullness. Arrange the following interventions in the most appropriate sequential order for the acute management of this patient.

A 52-year-old woman is evaluated in the hospital for a new-onset fever. She was admitted $12$ days ago for induction chemotherapy for acute myeloid leukemia. Her temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $114/72$ mm Hg, pulse is $98$/min, and respirations are $16$/min. Oxygen saturation is $98\%$ on room air. Physical examination reveals a right internal jugular central venous catheter; the insertion site is clean, dry, and without erythema or tenderness. There is no oral thrush or mucositis. Lung fields are clear to auscultation. The abdomen is soft and non-tender. Skin examination shows no rashes or induration.

Laboratory studies show:
Leukocyte count: $800/\text{mm}^3$
Absolute neutrophil count: $120/\text{mm}^3$
Hemoglobin: $8.4$ g/dL
Platelet count: $45,000/\text{mm}^3$

Urinalysis is negative for leukocyte esterase and nitrites. Chest radiography reveals no infiltrates. Blood and urine cultures are obtained. Which of the following is the most appropriate empiric pharmacotherapy for this patient?

A $52$-year-old man is evaluated in the intensive care unit on the third day of hospitalization for severe acute pancreatitis. The patient was initially admitted with severe epigastric pain and a serum lipase level of $3,500\text{ U/L}$. Over the first $48\text{ hours}$, he received aggressive fluid resuscitation with $12\text{ L}$ of intravenous lactated Ringer solution. Today, the nursing staff reports that he appears increasingly lethargic. His temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $108/65\text{ mmHg}$, pulse is $118/\text{min}$, and respirations are $24/\text{min}$. Physical examination shows generalized pitting edema and clear lungs bilaterally. The abdomen is significantly distended and diffusely tender to palpation without rigidity or guarding. Bowel sounds are absent.

Laboratory results are as follows:
Leukocyte count: $18,500/\text{mm}^3$
Blood urea nitrogen: $32\text{ mg/dL}$ (was $18\text{ mg/dL}$ on admission)
Serum creatinine: $1.9\text{ mg/dL}$ (was $0.9\text{ mg/dL}$ on admission)
Serum sodium: $138\text{ mEq/L}$
Serum potassium: $4.1\text{ mEq/L}$
Serum chloride: $104\text{ mEq/L}$
Serum bicarbonate: $16\text{ mEq/L}$

Arterial blood gas analysis on room air shows a pH of $7.32$, $\text{PaCO}_2$ of $30\text{ mmHg}$, and $\text{PaO}_2$ of $78\text{ mmHg}$.

A contrast-enhanced CT scan of the abdomen reveals diffuse enlargement of the pancreas with non-enhancement of approximately $50\%$ of the parenchyma, consistent with severe pancreatic necrosis. There are large peripancreatic fluid collections but no retroperitoneal gas is visualized.

Which of the following is the most appropriate next step in management?

A $68$-year-old man is evaluated in the hospital for new-onset diarrhea. He was admitted $8$ days ago for a chronic obstructive pulmonary disease (COPD) exacerbation and was treated with a $5$-day course of systemic glucocorticoids and levofloxacin. Over the last $48$ hours, he has had $6$ to $8$ watery bowel movements daily, accompanied by lower abdominal cramping and low-grade fever. Vitals: T $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), HR $92/\text{min}$, BP $118/76 \text{ mmHg}$. Physical examination reveals mild, diffuse abdominal tenderness with normal bowel sounds; there is no rebound tenderness or guarding. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$ and serum creatinine of $1.1 \text{ mg/dL}$ (baseline $0.9 \text{ mg/dL}$). Stool enzyme immunoassay is positive for *Clostridioides difficile* glutamate dehydrogenase antigen and toxins A and B. Which of the following is the most appropriate next step in management?

A $61$-year-old woman is transferred to the intensive care unit following endotracheal intubation for acute-on-chronic hypercapnic respiratory failure. She has a $45$-pack-year smoking history and severe chronic obstructive pulmonary disease. For the past three days, she has experienced progressive dyspnea, a severe productive cough with purulent sputum, and profound fatigue. Upon arrival at the emergency department, she was somnolent, and an arterial blood gas analysis revealed a pH of $7.22$, a PaCO $_2$ of $82\text{ mm Hg}$, and a PaO $_2$ of $56\text{ mm Hg}$ on room air. After a failed trial of non-invasive positive pressure ventilation, she was intubated.

Currently, her temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), pulse is $112\text{/min}$, blood pressure is $138/88\text{ mm Hg}$, and oxygen saturation is $94\%$ on a fraction of inspired oxygen (FiO $_2$) of $0.40$. Physical examination reveals a barrel-shaped chest with diffuse, bilateral end-expiratory wheezing and a prolonged expiratory phase. Cardiac auscultation reveals a rapid, regular rhythm without murmurs or gallops. There is no jugular venous distention or peripheral edema. Chest radiograph demonstrates hyperinflated lungs with flattened diaphragms, but no focal consolidations or pleural effusions.

Which of the following are appropriate components of the immediate management bundle for this patient? (Select all that apply)

A 64-year-old man presents to the emergency department with a 4-day history of worsening left lower quadrant abdominal pain, fever, and chills. His temperature is 38.6°C (101.5°F), blood pressure is 128/82 mmHg, and pulse is 98/min. Physical examination demonstrates a tender, palpable mass in the left lower quadrant. There is no diffuse rigidity or rebound tenderness. Laboratory tests show a leukocyte count of $17,500/\text{mm}^3$. Arrange the following management steps in the most appropriate chronological sequence for this patient's condition.

A 32-year-old woman presents to the emergency department complaining of sudden-onset, rapid heart palpitations and mild chest fullness that began 30 minutes ago while sitting at her desk. She denies syncope, severe shortness of breath, or chest pain. Her blood pressure is 115/75 mm Hg, pulse is 185/min, and respiratory rate is 16/min. Physical examination reveals regular, rapid heart sounds with no murmurs. An electrocardiogram demonstrates a regular, narrow-complex tachycardia with no discernible P waves.

Arrange the following interventions in the most appropriate sequential order for managing this patient's arrhythmia, assuming each preceding step fails to restore sinus rhythm.

Paramedics bring a 52-year-old unhoused man to the emergency department after he was found unresponsive in an alleyway during the winter. He has a known history of alcohol use disorder. On examination, he is obtunded and tachypneic.

Vital signs include a heart rate of $105/\text{min}$, blood pressure of $115/75 \text{ mmHg}$, and respiratory rate of $24/\text{min}$.

Laboratory studies reveal the following:

Arterial blood gas on room air shows a pH of $7.25$, $\text{pCO}_2$ of $28 \text{ mmHg}$, and $\text{pO}_2$ of $95 \text{ mmHg}$.

Based on the laboratory results provided, what is this patient's calculated serum osmolar gap in $\text{mOsm/kg}$?

A $22$-year-old man with a history of type 1 diabetes mellitus is brought to the emergency department due to severe abdominal pain, nausea, vomiting, and increasing lethargy over the past $24$ hours. His vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $90/60\text{ mm Hg}$, pulse of $122/\text{min}$, and respirations of $28/\text{min}$ with deep, sighing breaths. Physical examination reveals dry mucous membranes and poor skin turgor. Laboratory evaluation reveals the following:

Arrange the following management steps in the correct, priority-based chronological order for this patient.

Sixteen hours after undergoing a scheduled laparoscopic cholecystectomy for symptomatic cholelithiasis, a 34-year-old female patient is evaluated due to an elevated temperature. Her vitals indicate a core body temperature of 38.5°C (101.3°F), a blood pressure of 118/76 mmHg, a heart rate of 88/min, and a respiratory rate of 16/min. Pulse oximetry demonstrates 98% oxygen saturation on ambient air. The patient reports mild discomfort around the umbilical port site, for which she is receiving oral acetaminophen. She is tolerating a clear liquid diet and has ambulated to the bathroom independently. Physical examination demonstrates an abdomen that is soft and non-tender, with dry, intact surgical incisions. Cardiopulmonary auscultation reveals clear breath sounds bilaterally without crackles or wheezes, and regular heart sounds. There is no calf swelling or tenderness. Which of the following is the most appropriate next step in the management of this patient?

A 54-year-old woman with a history of metastatic breast cancer is brought to the emergency department due to progressive, severe dyspnea and lightheadedness over the last 48 hours. She is diaphoretic and tachypneic. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 82/52 mm Hg (which decreases to 68/46 mm Hg during inspiration), heart rate of 122/min, and respiratory rate of 26/min. Physical examination reveals jugular venous distention to the angle of the mandible while sitting at a 45-degree angle. Heart sounds are distant. Lungs are clear to auscultation bilaterally. Electrocardiography demonstrates sinus tachycardia with low QRS voltage and beat-to-beat variation in the QRS complex amplitude. Arrange the following management steps in the most appropriate chronological sequence for this patient's acute presentation.

A $42$-year-old man presents to a busy urgent care clinic with a $5$-week history of worsening cough producing blood-tinged sputum, drenching night sweats, and an $8$-kg ($17.6$-lb) weight loss. He immigrated to the United States from a highly endemic region $3$ years ago. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, pulse is $88\text{/min}$, and respiratory rate is $18\text{/min}$. He is currently seated in the crowded main waiting room.

Arrange the following steps in the most appropriate chronological order for the initial workup and management of this patient.

A 68-year-old man is brought to the emergency department due to worsening shortness of breath, a productive cough, and progressive lethargy over the past 3 days. He has a history of severe chronic obstructive pulmonary disease (COPD) and heart failure with a reduced ejection fraction. One week ago, his primary care physician doubled his daily dose of oral furosemide due to increased lower extremity edema. On physical examination, his temperature is 37.2°C (99.0°F), blood pressure is 110/70 mm Hg, pulse is 98/min, and respiratory rate is 14/min. He is somnolent but arousable. Lung auscultation reveals diffuse expiratory wheezes and prolonged expiration. There is no lower extremity edema.

Arterial blood gas on room air:
pH: 7.37
$pCO_2$: 80 mm Hg
$pO_2$: 55 mm Hg

Serum chemistry:
Sodium: 137 mEq/L
Potassium: 2.9 mEq/L
Chloride: 80 mEq/L
Bicarbonate: 45 mEq/L

Which of the following best describes this patient's acid-base disorder?

A 24-year-old woman comes to the clinic for a routine health maintenance examination. She reports feeling well overall, though she notes occasional mild palpitations when she consumes excessive caffeine. She has no history of weight loss, heat intolerance, changes in bowel habits, or tremors. Four months ago, she was prescribed a combined oral contraceptive pill. Her only other medication is a daily multivitamin. Vital signs are within normal limits, with a pulse of $74/\text{min}$ and a blood pressure of $118/76\text{ mmHg}$. Physical examination reveals a normal-sized thyroid gland without palpable nodules. Deep tendon reflexes are $2+$ bilaterally. Laboratory studies show the following:

Which of the following is the most appropriate next step in management?

Match each classic cardiac auscultation finding with the valvular pathology it most accurately describes.

An $82$-year-old man is evaluated on postoperative day $2$ following an elective right total hip arthroplasty due to the sudden onset of shortness of breath and mild agitation. His medical history is significant for a $35$-pack-year smoking history with known chronic obstructive pulmonary disease (COPD), major depressive disorder managed with citalopram, and diet-controlled type 2 diabetes mellitus. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $168/94\text{ mmHg}$, heart rate is $114/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows $87\%$ on room air. Physical examination reveals an elevated jugular venous pressure of $11\text{ cm H}_2\text{O}$. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. Lung auscultation demonstrates diffuse, bilateral expiratory wheezes. The surgical incision is clean and intact. The lower extremities exhibit 2+ bilateral pitting edema. Initial laboratory studies show a normal complete blood count and a basic metabolic panel within normal limits. Thyroid studies reveal a thyroid-stimulating hormone (TSH) level of $1.4\text{ }\mu\text{U/mL}$ (normal: $0.4-4.0\text{ }\mu\text{U/mL}$) and a free T4 level of $0.6\text{ ng/dL}$ (normal: $0.9-1.7\text{ ng/dL}$). Which of the following is the most appropriate next step in the management of this patient?

Review the clinical scenarios described below. Match each clinical presentation of a gastrointestinal or abdominal pathology with its most appropriate primary surgical or procedural intervention.

A 68-year-old male is evaluated on postoperative day 6 following an emergent exploratory laparotomy and bowel resection for perforated diverticulitis. He has a history of poorly controlled diabetes mellitus and chronic obstructive pulmonary disease. While coughing forcefully, he feels a sudden "giving way" sensation in his abdomen. The nurse reports a large amount of salmon-colored fluid draining from the surgical site. Physical examination reveals a separation of the midline fascial closure with a segment of small intestine protruding through the defect. His blood pressure is 130/80 mm Hg and pulse is 95/min. Arrange the following management steps in the most appropriate chronological sequence for this patient.