All practice questions

A 62-year-old woman presents to the emergency department with sudden-onset, severe, tearing chest pain radiating to her upper back. Her blood pressure is 195/110 mm Hg and heart rate is 112/min. A bedside chest radiograph shows a widened mediastinum. The physician suspects an acute aortic dissection. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient.

A 62-year-old man is brought to the emergency department complaining of sudden-onset, severe, 'tearing' chest pain that radiates to between his shoulder blades. His blood pressure is 210/115 mm Hg in the right arm and 170/95 mm Hg in the left arm. His heart rate is 112/min. A chest x-ray reveals a widened mediastinum. The clinical suspicion for an acute aortic dissection is very high. Arrange the following steps in the most appropriate sequential order for the acute management of this patient.

A 54-year-old man is admitted to the intensive care unit with severe bilateral pneumonia and subsequently develops acute respiratory distress syndrome (ARDS). The clinical team decides to initiate invasive mechanical ventilation due to worsening hypoxemia and respiratory fatigue. Arrange the following steps in the standard sequential order for the management of severe ARDS, proceeding from the initial ventilator setup to advanced therapies.

A $45$-year-old man is receiving mechanical ventilation in the intensive care unit for acute respiratory distress syndrome (ARDS). The ventilator alarm suddenly sounds for high peak airway pressures. The patient's blood pressure drops abruptly from $110/70$ mm Hg to $70/40$ mm Hg, and his oxygen saturation falls to $82\%$. Physical examination reveals absent breath sounds on the right side, hyperresonance to percussion, and the trachea is deviated to the left. Arrange the following interventions in the most appropriate chronological order to manage this acute life-threatening event.

A $62$-year-old male with a history of pulmonary tuberculosis treated $15$ years ago is brought to the emergency department for massive hemoptysis. He reports coughing up approximately $800\text{ mL}$ of bright red blood over the past two hours. He is visibly anxious, diaphoretic, and in respiratory distress. Vital signs are temperature $37.1^\circ\text{C}$, blood pressure $88/54\text{ mmHg}$, heart rate $126/\text{min}$, respiratory rate $30/\text{min}$, and oxygen saturation $85\%$ on room air. Auscultation reveals loud, coarse crackles and diminished breath sounds isolated to the right lung fields; the left lung fields are clear. A chest radiograph from two months ago documented a large, thick-walled cavitary lesion in the right upper lobe. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $41$-year-old woman with a history of cystic fibrosis presents to the emergency department after coughing up large volumes of bright red blood. She estimates expectorating over $600$ mL of blood since this morning. On arrival, she is in severe respiratory distress, coughing persistently, and unable to speak in full sentences.

Vital signs:
Temperature: $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$)
Blood pressure: $100/60$ mmHg
Heart rate: $118$/min
Respiratory rate: $30$/min
Oxygen saturation: $86\%$ on room air

A bedside chest radiograph demonstrates extensive bronchiectasis, predominantly in the right upper and middle lobes, with new dense alveolar opacities in the left lower lobe.

Arrange the following interventions in the correct sequential order of management, from the immediate life-saving stabilization step to the definitive last-resort therapy.

A 34-year-old man with advanced, untreated HIV infection is evaluated in the emergency department for a two-week history of constant, severe headaches, low-grade fevers, and intermittent nausea. He appears lethargic. Vital signs show a temperature of 38.1°C (100.6°F), blood pressure of 118/76 mmHg, and a heart rate of 92/min. Neurologic examination shows mild nuchal rigidity but no focal deficits. Laboratory studies confirm a CD4 count of 18 cells/mm³. A lumbar puncture is performed, demonstrating an elevated opening pressure of 290 mm H2O. Cerebrospinal fluid (CSF) analysis reveals 45 leukocytes/mm³ (90% lymphocytes), a glucose level of 32 mg/dL, and a protein level of 88 mg/dL. A CSF India ink stain displays encapsulated budding yeast, and the cryptococcal antigen assay is profoundly positive.

Arrange the following therapeutic interventions in the most appropriate chronological order of their initiation for the optimal management of this patient.

An emergency medical services team arrives at the hospital with an altered, lethargic male patient who was found severely confused at home by his family. The patient is $68$ years old and has a known history of extensive tobacco use ($40$ pack-years). According to his family, he has experienced worsening constipation and fatigue over the last seven days. Vital signs upon arrival include a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), a blood pressure of $98/58\text{ mm Hg}$, and a heart rate of $112/\text{min}$. Clinical evaluation demonstrates pronounced signs of volume depletion, including parched oral mucosa and delayed capillary refill. Urgent serum chemistries reveal a total calcium concentration of $15.6\text{ mg/dL}$, an albumin concentration of $3.8\text{ g/dL}$, and a creatinine of $2.1\text{ mg/dL}$ (previously $0.9\text{ mg/dL}$). An electrocardiogram demonstrates a shortened QT interval.

Arrange the following therapeutic and diagnostic interventions in the most appropriate chronological sequence for managing this patient's acute presentation, from immediate life-saving stabilization to definitive evaluation.

A $52$-year-old man is evaluated in the clinic for persistently elevated blood pressure. He is currently taking maximally tolerated doses of lisinopril, amlodipine, and hydrochlorothiazide. His blood pressure today is $168/94\text{ mmHg}$, and his heart rate is $76\text{/min}$. Laboratory studies reveal a serum potassium level of $3.0\text{ mEq/L}$ and a serum sodium level of $144\text{ mEq/L}$. The patient's antihypertensive regimen is transitioned to non-interfering medications (e.g., verapamil and doxazosin), and his hypokalemia is corrected with oral potassium supplementation. The physician strongly suspects a specific endocrine etiology for his resistant hypertension and hypokalemia. Arrange the following diagnostic steps in the most appropriate chronological sequence to definitively evaluate and manage this patient's suspected condition.

A 48-year-old man presents to the clinic reporting progressive enlargement of his hands and feet over the past $4$ years. He recently had to resize his wedding ring and notes that his shoes no longer fit. He also complains of increased sweating, joint pain, and frequent frontal headaches. His wife mentions that his jaw has become more prominent and there are new gaps between his teeth. His blood pressure is $165/95$ mmHg. Arrange the following steps in the most appropriate chronological order for the diagnostic workup and initial definitive management of this patient's suspected condition.

A $42$-year-old woman is brought to the emergency department by her husband due to progressive confusion, lethargy, and a low-grade fever over the past $24$ hours. She has no significant past medical history. Her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $142/88$ mmHg, and pulse is $105$/min. Physical examination reveals petechiae on her lower extremities and scleral icterus. Neurologic examination shows a lethargic patient who is oriented only to person.

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

A 4-day-old male neonate is brought to the emergency department due to poor feeding, vomiting, and progressive unresponsiveness over the past 12 hours. He was born at 39 weeks gestation via uncomplicated vaginal delivery and was discharged on day 2 of life feeding well. On examination, the infant is comatose, hypothermic (35.4°C), and tachypneic. While being examined, he develops generalized tonic-clonic seizure activity. Initial laboratory evaluation reveals:

Sodium: 140 mEq/L
Potassium: 4.5 mEq/L
Chloride: 105 mEq/L
Bicarbonate: 22 mEq/L
Blood urea nitrogen: 4 mg/dL
Creatinine: 0.3 mg/dL
Glucose: 55 mg/dL
Arterial blood gas: pH 7.52, pCO2 25 mmHg, pO2 95 mmHg
Plasma ammonia: 1,250 µmol/L (normal: 15-50 µmol/L)

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

A 10-day-old male neonate is evaluated in the pediatric orthopedics clinic for bilateral foot abnormalities present since birth. The pregnancy was uncomplicated, and he was born at term via spontaneous vaginal delivery. On physical examination, both feet exhibit deep medial creases, plantar flexion of the ankles, inversion of the heels, and medial deviation of the forefeet. The deformities are rigid and cannot be passively manipulated into a neutral position. There are no dimples over the sacrum, and lower extremity reflexes are normal. The physician discusses the standard evidence-based, nonoperative management protocol with the parents. Arrange the following steps of the standard treatment protocol for this patient's condition in the correct chronological sequence.

An 8-month-old girl with an unrepaired congenital heart defect presents to the acute care clinic with sudden, severe cyanosis and inconsolable crying that began after feeding. Her parents state she has had milder episodes like this before, but they usually resolved quickly. On examination, the infant is highly agitated and has marked circumoral cyanosis. Her peripheral oxygen saturation is 60% on room air. A systolic ejection murmur is auscultated at the left mid-to-upper sternal border, though it is currently faint. The clinical picture is consistent with a hypercyanotic (tet) spell.

Arrange the following interventions in the correct chronological sequence for the acute management of this patient's condition, starting from the immediate initial response to the final definitive treatment step.

A healthy 24-year-old primigravida presents for preconception counseling. She is subsequently confirmed pregnant and initiates prenatal care at 8 weeks gestation. Her initial laboratory workup reveals she is blood type A-negative. Assuming an uncomplicated pregnancy course that concludes with the term vaginal delivery of a healthy Rh(D)-positive neonate, arrange the following routine alloimmunization screening and prophylaxis steps in the correct chronological sequence from the first trimester through the postpartum period.

A 4-year-old girl is brought to the clinic by her parents due to a two-week history of worsening fatigue, spontaneous bruising on her legs, and intermittent low-grade fevers. Physical examination reveals generalized lymphadenopathy and mild hepatosplenomegaly. The physician suspects acute lymphoblastic leukemia (ALL). Arrange the following diagnostic steps in the most appropriate chronological order, from initial screening to definitive staging.

A $24$-year-old woman, gravida $1$, para $0$, presents to the clinic at $8$ weeks gestation for her initial prenatal visit. Her medical history is unremarkable, and she takes a daily prenatal vitamin. Her blood pressure is $112/70\text{ mmHg}$, and her body mass index is $22\text{ kg/m}^2$. The patient is eager to ensure a healthy pregnancy and asks the physician to outline the standard schedule of recommended screenings and evaluations she will undergo over the coming months.

Arrange the following routine obstetric interventions for this patient in the correct chronological order from earliest to latest gestational age.

A 29-year-old multiparous patient at 39 weeks gestation undergoes a spontaneous vaginal delivery. During the third stage of labor, excessive traction is applied to the umbilical cord before placental separation. The patient suddenly develops severe lower abdominal pain and profuse vaginal bleeding. On physical examination, a firm, beefy-red mass is protruding from the introitus, and the uterine fundus is not palpable transabdominally. The patient is tachycardic and hypotensive.

Arrange the following management steps in the optimal chronological sequence, assuming each initial intervention is unsuccessful until surgical resolution is required, followed by standard post-correction care.

A seven-year-old girl with a history of retroperitoneal neuroblastoma is brought to the emergency department due to severe, worsening mid-back pain for the past three days and new-onset difficulty walking over the last twelve hours. Her parents report she has not voided urine since yesterday evening. Vital signs are within normal limits for her age. Neurologic examination reveals grade three out of five motor strength in the bilateral lower extremities, hyperreflexia at the patellae, and decreased sensation to light touch below the umbilicus. The bladder is palpably distended. Arrange the following management steps in the most appropriate chronological sequence for this patient's suspected complication.

Paramedics arrive at the emergency department with a 4-week-old infant who is lethargic and feverish. The infant's parents report a 12-hour history of explosive, foul-smelling diarrhea and progressive abdominal swelling. Medical history is notable for delayed meconium passage after birth, which required a glycerin suppository. Vital signs show a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), a heart rate of $185\text{/min}$, a respiratory rate of $60\text{/min}$, and a blood pressure of $58/30\text{ mm Hg}$. The capillary refill time is 4 seconds. On physical examination, the infant is poorly responsive and has a markedly distended, tense abdomen. The clinical picture is highly suspicious for Hirschsprung-associated enterocolitis complicated by septic shock.

Arrange the following management steps in the most appropriate chronological sequence for this patient's immediate care.