All practice questions

A 24-year-old medical student is diagnosed with a first episode of major depressive disorder. After ruling out any history of mania or hypomania, the physician prescribes a selective serotonin reuptake inhibitor (SSRI). The physician provides comprehensive anticipatory guidance regarding the expected treatment timeline. Arrange the following clinical events in the standard chronological order of their expected occurrence during a successful, uncomplicated course of SSRI therapy.

A 78-year-old man develops progressive abdominal distention over the past 48 hours. He is currently on postoperative day 4 following a right total knee arthroplasty. His medical history is significant for hypertension and osteoarthritis. Current medications include patient-controlled intravenous morphine. Vital signs are within normal limits. Physical examination reveals a massively distended, tympanitic abdomen with mild diffuse tenderness but no guarding or rebound. Bowel sounds are hypoactive. An upright abdominal radiograph demonstrates diffuse colonic dilation with a cecal diameter of 11.5 cm and no air-fluid levels or free air. The patient is diagnosed with acute colonic pseudo-obstruction (Ogilvie syndrome). Assuming the patient's condition does not resolve with each successive intervention and he remains hemodynamically stable without signs of perforation, arrange the following management options in the correct sequential order from initial step to most definitive last-resort therapy.

A $32$-year-old man is brought to the trauma bay via ambulance after being ejected from a vehicle during a high-speed rollover collision. On arrival, he is unresponsive. Vital signs show a blood pressure of $75/40$ mm Hg, a heart rate of $142$/min, and a respiratory rate of $6$/min with shallow, gurgling respirations. Paramedics report a large, deep laceration on his left mid-thigh that is actively spurting bright red blood. According to standard trauma resuscitation protocols, arrange the following initial management steps in the correct chronological order.

A 45-year-old woman is evaluated in the post-anesthesia care unit 2 hours after a total thyroidectomy for a large multinodular goiter. The nurse urgently calls for assistance because the patient has suddenly developed severe respiratory distress. Her temperature is 37.1°C (98.8°F), blood pressure is 155/92 mm Hg, pulse is 118/min, and respirations are 28/min. Pulse oximetry shows an oxygen saturation of 88% on room air. Physical examination reveals a tense, rapidly expanding swelling beneath the cervical incision and prominent inspiratory stridor. Arrange the following management steps in the most appropriate chronological order.

A 68-year-old man with a history of poorly controlled diabetes mellitus and chronic obstructive pulmonary disease is evaluated on postoperative day 6 following an emergent open cholecystectomy for gangrenous cholecystitis. While attempting to transfer from his bed to a chair, he experiences a sudden, severe fit of coughing followed by a "tearing" sensation in his abdomen. On examination, his surgical dressing is saturated with serosanguinous fluid. Removal of the dressing reveals that the fascial edges of his midline incision have separated, and loops of small bowel are protruding onto the abdominal wall.

Arrange the following management steps in the most appropriate chronological sequence for this acute postoperative complication.

A $28$-year-old male is brought to the trauma bay after a high-speed motorcycle collision. Emergency medical services report a prolonged scene time. On arrival, the patient is unresponsive. There is active, pulsatile bleeding from a traumatic partial amputation of the left lower leg. He has severe maxillofacial smash injuries with pooling of blood and vomitus in the oropharynx. Breath sounds are absent on the right side, and the trachea is deviated to the left. His blood pressure is $70/40$ mm Hg, and his heart rate is $145$/min. Arrange the following initial management steps in the correct chronological sequence according to the current Advanced Trauma Life Support (ATLS) primary survey protocol.

A 62-year-old man presents to the emergency department with a 1-day history of fever, severe right upper quadrant abdominal pain, and confusion. His temperature is 39.2°C (102.6°F), blood pressure is 88/56 mmHg, and heart rate is 118/min. Physical examination reveals pronounced scleral icterus and right upper quadrant tenderness without rebound or guarding. Laboratory studies show a leukocyte count of 18,000/mm³, total bilirubin of 6.8 mg/dL, and alkaline phosphatase of 480 U/L.

Arrange the following management steps in the most appropriate sequential order for this patient, from immediate priority to definitive long-term treatment.

A 32-year-old recreational skier is admitted after sustaining a closed diaphyseal fracture of the right tibia. Following closed reduction and immobilization in a circumferential long-leg cast, he is monitored on the orthopedic ward. Fourteen hours later, he develops excruciating leg pain that worsens with passive movement and is entirely refractory to high-dose intravenous analgesia. Arrange the following clinical steps in the appropriate chronological sequence for the definitive management of this patient's evolving condition.

A 32-year-old male is brought to the emergency department via ambulance after being involved in a high-speed motor vehicle collision. Primary and secondary trauma surveys reveal that he is hemodynamically stable with no life-threatening injuries. The patient reports excruciating left hip pain and is unable to move his left leg. On physical examination, the left lower extremity is shortened, internally rotated, and adducted. The skin is intact. Initial assessment reveals palpable dorsalis pedis and posterior tibial pulses, as well as normal sensation over the dorsum and plantar aspects of the left foot.

Arrange the following interventions in the most appropriate chronological sequence for the definitive evaluation and management of this patient's orthopedic injury.

A 68-year-old woman with a history of atrial fibrillation presents to the emergency department with a 3-hour history of sudden, severe right leg pain. On physical examination, her right lower extremity is pale and cold. Femoral pulses are palpable bilaterally, but right popliteal and pedal pulses are absent. Bedside Doppler evaluation reveals absent arterial signals but audible venous signals in the right foot. Motor function is intact, and there is mild sensory loss in the toes. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 35-year-old man with a history of schizoaffective disorder is admitted to the inpatient psychiatric unit due to an acute exacerbation of psychotic symptoms. He is started on fluphenazine. Three days later, the nursing staff finds him confused and diaphoretic. Vital signs show a temperature of 39.5°C (103.1°F), blood pressure of 160/100 mmHg, and heart rate of 122/min. Physical examination reveals profound lead-pipe muscle rigidity. Laboratory studies demonstrate a markedly elevated serum creatine kinase (CK) level and leukocytosis. Arrange the following steps in the management of this patient's current condition in the most appropriate sequential order, from the initial, most critical action to treatments reserved for refractory cases.

A 24-year-old man is diagnosed with schizophrenia after presenting with a 7-month history of auditory hallucinations and persecutory delusions. His psychiatrist is planning a long-term pharmacotherapy strategy. Assuming the patient exhibits an inadequate clinical response to each consecutive intervention despite optimal dosing and confirmed medication adherence, arrange the following treatment steps in the correct standard algorithm for the management of schizophrenia.

A third-year internal medicine resident notices that their supervising attending physician smells strongly of alcohol, has slurred speech, and is unsteady on their feet right before starting a shift in the intensive care unit. Arrange the following steps in the most appropriate order of action and escalation to manage this professional concern.

A 48-year-old man is admitted to the intensive care unit following a massive subarachnoid hemorrhage. He is comatose, permanently lacks decision-making capacity, and his prognosis is extremely poor. The medical team is considering transitioning to comfort measures only. The patient has no written advance directive and has never designated a healthcare proxy. Several individuals are present at the hospital and disagree on the plan of care. According to the standard legal hierarchy of surrogate decision-makers, arrange the following individuals in order of their legal priority to make medical decisions on the patient's behalf, from highest priority (first) to lowest priority (last).

A 64-year-old woman is treated for a pulmonary embolism. During her hospitalization, she receives an incorrect dose of intravenous heparin due to a weight-conversion error (pounds instead of kilograms). The error results in a supratherapeutic partial thromboplastin time and minor mucosal bleeding, which resolves after the infusion is temporarily paused. The hospital's quality and safety committee initiates a formal root cause analysis (RCA) to investigate the incident and prevent future occurrences.

Arrange the following steps of the root cause analysis process in the correct chronological sequence.

An attending physician realizes they accidentally prescribed a ten-fold overdose of an anticoagulant, which a nurse has just administered to the patient. Arrange the following steps in the most appropriate chronological order for managing this medical error according to professional and ethical guidelines.

A tertiary care hospital is preparing to integrate a novel, highly automated intravenous chemotherapy administration system across its oncology wards. In an effort to proactively prevent adverse drug events before the system is implemented, the medical executive committee mandates a Failure Mode and Effects Analysis (FMEA). Arrange the following procedural steps of this prospective quality improvement tool in the correct chronological sequence, from initial action to final implementation.

A 54-year-old woman is intubated and sedated in the intensive care unit following a severe asthma exacerbation that progressed to hypoxic respiratory failure. She currently lacks decision-making capacity. The clinical team determines that a tracheostomy is medically indicated and needs consent to proceed. A thorough search of her medical records and personal belongings reveals no advance directive, living will, or designated healthcare proxy. Several individuals have arrived at the hospital, each expressing strong opinions about her care and offering to provide consent.

According to standard legal and ethical consensus for surrogate decision-making, arrange the following individuals in order of their statutory priority to act as the patient's surrogate decision-maker, from highest priority (first) to lowest priority (last).

A hospital is preparing to transition to a new automated medication dispensing cabinet system in the emergency department. To proactively identify and mitigate potential safety risks before the system goes live, hospital leadership initiates a Failure Mode and Effects Analysis (FMEA). Arrange the following steps of the FMEA in the correct sequential order.

The chief medical officer of a tertiary care center receives an incident report detailing a near-miss event in the neonatal intensive care unit. An infant was nearly administered an inappropriate adult formulation of intravenous levetiracetam. Preliminary investigation reveals that the electronic barcode scanner was nonfunctional, prompting the bedside nurse to manually override the safety alert to administer the medication on time. To prevent future occurrences and address systemic vulnerabilities, quality improvement leadership initiates a formal Root Cause Analysis (RCA). Arrange the following steps in the correct procedural sequence for executing this comprehensive RCA.