All practice questions

A 24-year-old nulliparous woman presents to the clinic reporting that she has not had a menstrual period for the past 6 months. Her menarche occurred at age 12, and her menses were previously regular, occurring every 28 days. She takes no medications, has no chronic medical conditions, and is sexually active with a male partner. Her vital signs and physical examination are unremarkable. Arrange the following diagnostic steps in the most appropriate chronological sequence for the evaluation of this patient's secondary amenorrhea, starting with the immediate first step.

A 27-year-old female presents to the outpatient clinic reporting an absence of menstruation for the past seven months. She previously experienced predictable cycles every 29 days. She denies hot flashes, nipple discharge, vision changes, or recent alterations in body weight. Physical examination shows a normal female escutcheon, no signs of hyperandrogenism, and an unremarkable bimanual pelvic examination. Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's condition, starting with the mandatory initial test.

A 24-year-old healthy female presents to the clinic reporting an absence of menses for the past six months. She previously had regular 28-day menstrual cycles. She does not take any medications, has no chronic medical conditions, and reports no breast discharge, visual changes, or hot flashes. Physical examination reveals a normal body mass index and normal secondary sexual characteristics. Arrange the following diagnostic steps in the most appropriate chronological sequence for the initial evaluation of this patient's secondary amenorrhea, starting with the most immediate first step.

A 42-year-old man is brought to the emergency department by police due to erratic behavior in public. He is pacing the evaluation room, speaking loudly, and appears acutely agitated. He has not yet committed any acts of physical violence but is becoming increasingly uncooperative and hostile. Arrange the following interventions in the standard stepwise order for managing this acutely agitated patient, from the initial, least restrictive measure to the final, most restrictive measure.

A 28-year-old woman is brought to the trauma bay by emergency medical services after being ejected from a motorcycle at highway speeds. She is confused, tachypneic, and covered in significant abrasions. According to Advanced Trauma Life Support (ATLS) principles, arrange the following initial assessment and management steps in the correct chronological order.

A 68-year-old woman with a history of permanent atrial fibrillation and hypertension presents to the emergency department with a 3-hour history of sudden-onset, severe right leg pain. She admits to running out of her oral anticoagulant medication a week ago. On physical examination, the right foot and distal calf are pale and cool to the touch. Sensation to light touch is intact, and she can move all her toes without difficulty. Capillary refill is delayed. Palpation reveals a normal femoral pulse, but popliteal and pedal pulses are absent.

Arrange the following steps in the most appropriate sequential order for the evidence-based management of this patient's condition.

A 28-year-old male is brought to the emergency department after a severe crush injury to his pelvis at a construction site. He is hemodynamically stable. Physical examination reveals a pelvic binder in place, blood at the urethral meatus, and a high-riding prostate on digital rectal examination. A FAST exam is negative. He has a palpable, distended bladder and reports a strong urge to urinate. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological order for the urologic management of this patient.

A 58-year-old man undergoes a thoracentesis for a large right-sided pleural effusion. Due to a misreading of the imaging orientation on a portable ultrasound and a rushed timeout process, the physician inserts the needle into the left hemithorax. The patient develops a sudden drop in oxygen saturation and absent breath sounds on the left.

Arrange the following subsequent steps in the correct chronological sequence for managing this sentinel event according to standard patient safety, risk management, and ethical guidelines.

A second-year anesthesiology resident is preparing a patient for a complex elective spinal fusion. The patient is awake on the operating table, and induction has not yet begun. The attending orthopedic surgeon enters the operating room to examine the surgical site. The resident notices that the surgeon has a strong odor of alcohol, is uncharacteristically irritable, and exhibits a fine motor tremor. Arrange the following actions and institutional responses in the correct procedural and chronological order, prioritizing immediate patient safety and adhering to standard professional guidelines for managing an impaired physician.

A third-year internal medicine resident is completing a research rotation under the supervision of a prominent Principal Investigator (PI). The PI is leading an industry-sponsored, phase III randomized controlled trial evaluating a novel biologic agent for severe rheumatoid arthritis. While reviewing patient charts in preparation for an upcoming monitoring visit, the resident discovers that the PI recently enrolled three patients who had a documented history of latent tuberculosis. According to the study guidelines, a history of latent tuberculosis is a strict exclusion criterion due to the risk of fatal reactivation. All three patients have already received their first dose of the experimental biologic. Arrange the following steps in the most appropriate ethical and regulatory sequence of escalation for managing this suspected protocol violation.

An institutional Conflict of Interest (COI) Committee is evaluating a Principal Investigator's newly declared financial relationship with a biotechnology startup. The startup manufactures a novel surgical device that the investigator plans to evaluate in an upcoming federally funded clinical trial. To protect the integrity of the research and ensure patient safety, the committee must implement a progressive management plan. Arrange the following potential conflict of interest management strategies in sequential order from the LEAST restrictive (baseline transparency) to the MOST restrictive (severe mitigation).

A 34-year-old woman with no significant past medical history is evaluated in the clinic for a 6-month history of progressively worsening exertional dyspnea and fatigue. She has no cough, wheezing, orthopnea, or leg swelling. She does not smoke. Vital signs are within normal limits. Physical examination reveals a prominent right ventricular heave, a loud pulmonic component of the second heart sound (P2), and a faint holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. The lungs are clear to auscultation bilaterally. Electrocardiogram shows right axis deviation and right ventricular hypertrophy. Suspecting a primary pulmonary vascular disorder, the physician plans a comprehensive diagnostic workup.

Arrange the following diagnostic and management steps in the correct chronological sequence according to consensus guidelines for unexplained pulmonary hypertension, moving from initial screening to definitive management:

A 45-year-old man is brought to the emergency department by his wife due to a 24-hour history of high fever, severe headache, and progressively worsening confusion. On physical examination, his temperature is 39.2°C (102.6°F), blood pressure is 130/80 mm Hg, and heart rate is 110/min. He has marked nuchal rigidity. Neurologic examination reveals a lethargic patient who only opens his eyes to painful stimuli. He demonstrates mild left-sided hemiparesis. Arrange the following steps in the most appropriate chronological sequence for the initial management of this patient.

A $64$-year-old man is brought to the emergency department by ambulance due to the sudden onset of severe, "tearing" chest pain that radiates to his interscapular region. He has a history of poorly controlled hypertension. On arrival, he appears diaphoretic and in severe distress. His blood pressure is $210/115\text{ mmHg}$ in the right arm and $170/95\text{ mmHg}$ in the left arm. His heart rate is $115\text{/min}$. A portable chest radiograph reveals a widened mediastinum. An acute aortic dissection is highly suspected. Arrange the following next steps in the most appropriate chronological sequence for the initial management of this patient.

A 32-year-old woman presents to the outpatient clinic with a 1-day history of right-sided pleuritic chest pain and mild dyspnea. Her vital signs show a temperature of 37.1°C (98.8°F), pulse of 92/min, respiratory rate of 16/min, and blood pressure of 118/76 mm Hg. Oxygen saturation is 99% on room air. She has no history of venous thromboembolism, recent surgery, or immobilization. Her physical examination is unremarkable. Arrange the following diagnostic steps in the most appropriate sequential order for the evaluation of this patient.

A 34-year-old woman presents to the emergency department complaining of a sudden-onset "racing heart" and mild palpitations that began 30 minutes ago. She has no significant past medical history and takes no medications. On evaluation, she is alert, oriented, and conversing comfortably. Her blood pressure is 118/76 mmHg, pulse is 185/min, and respiratory rate is 18/min. Cardiopulmonary examination is otherwise unremarkable, with clear lungs and no murmurs. An electrocardiogram reveals a regular, narrow-complex tachycardia at a rate of 185/min with no discernible P waves. Assuming the patient's hemodynamic status remains stable but the arrhythmia is refractory to each successive intervention, arrange the following management steps in the correct chronological sequence according to standard clinical algorithms.

A 65-year-old man arrives at the emergency department reporting sudden-onset, severe, tearing chest pain that radiates to his back. His blood pressure is 195/110 mm Hg in both arms, and his heart rate is 112/min. A chest radiograph demonstrates a widened mediastinum. A presumptive clinical diagnosis of acute aortic dissection is made. Arrange the following management steps in the correct chronological sequence to safely stabilize and evaluate this patient.

A 32-year-old woman presents to the clinic with a 6-month history of progressive exertional dyspnea and fatigue. She has no history of smoking, asthma, or illicit drug use, and takes no medications. Physical examination reveals a prominent right ventricular heave, a loud pulmonic component of the second heart sound ($P_2$), and trace bilateral lower extremity edema. The lungs are clear to auscultation. Electrocardiography demonstrates right axis deviation and right ventricular hypertrophy. Arrange the following steps in the most appropriate sequential order for the comprehensive diagnostic evaluation and initial management of this patient's suspected condition.

An emergency medical crew brings a 45-year-old man to the hospital due to a one-week history of high fevers, intense chills, and severe fatigue. He has a known history of intravenous heroin use. Upon arrival in the acute care unit, his temperature is 39.1°C (102.4°F), blood pressure is 110/65 mm Hg, and pulse is 112/min. Physical examination reveals a loud III/VI holosystolic murmur best heard at the left lower sternal border that increases in intensity with inspiration. Small, tender, erythematous nodules are noted on the pads of his fingers. Arrange the following steps in the most appropriate chronological sequence for the initial diagnostic evaluation and management of this patient.

A 68-year-old man is hospitalized for community-acquired pneumonia and treated with intravenous ceftriaxone and azithromycin. On day 5 of his admission, he develops new-onset frequent, watery diarrhea, mild diffuse abdominal pain, and a temperature of 38.2°C (100.8°F). His vital signs are otherwise stable, and physical examination reveals mild lower abdominal tenderness without rebound or guarding. The medical team suspects an infectious complication related to his recent pharmacotherapy. Arrange the following management steps in the most appropriate chronological sequence for addressing this new complication.