All practice questions

A 29-year-old multiparous patient at 40 weeks gestation is in the second stage of labor. Following the delivery of the fetal head, it retracts tightly against the maternal perineum ('turtle sign'). Gentle downward traction fails to deliver the anterior shoulder. Arrange the following steps in the most appropriate sequence of escalation for managing this obstetric emergency according to standard protocols.

A 25-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He is unresponsive and has sustained multiple injuries. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial management steps of the primary survey in the correct chronological order.

A $58$-year-old man is brought to the emergency department by emergency medical services due to the sudden onset of severe, 'tearing' chest pain that radiates to his back between the scapulae. The pain started abruptly $45$ minutes ago while he was doing yard work. He has a history of poorly controlled essential hypertension. On arrival, he is diaphoretic and appears in acute distress. His temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $195/110$ mmHg in the right arm and $180/105$ mmHg in the left arm, heart rate is $108$/min, and respiratory rate is $22$/min. Oxygen saturation is $96\%$ on room air. A bedside chest radiograph reveals a widened mediastinum. Arrange the following management steps in the most appropriate chronological order for this patient.

A 58-year-old female patient is evaluated in the emergency room due to a $2$-day history of severe right upper quadrant abdominal pain, shaking chills, and progressively worsening yellowing of her skin. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $98/60$ mm Hg, pulse is $112$/min, and respirations are $20$/min. Physical examination reveals marked scleral icterus and significant right upper quadrant tenderness, but no rebound or guarding.

Laboratory studies show:
Leukocyte count: $18,500/\text{mm}^3$
Total bilirubin: $6.4 \text{ mg/dL}$
Alkaline phosphatase: $480 \text{ U/L}$
Aspartate aminotransferase (AST): $150 \text{ U/L}$
Alanine aminotransferase (ALT): $165 \text{ U/L}$
Amylase: $85 \text{ U/L}$

Arrange the following interventions in the most appropriate chronological sequence for the management of this patient's condition.

The quality improvement committee at a large community hospital has identified a recent increase in central line-associated bloodstream infections (CLABSIs) within the intensive care unit. The committee decides to implement a new daily central line maintenance checklist to standardize care and reduce infection rates. They plan to use the Plan-Do-Study-Act (PDSA) cycle to guide this quality improvement initiative.

Arrange the following actions taken by the committee in the correct chronological sequence according to the PDSA methodology.

A 65-year-old man is admitted to the intensive care unit following a massive ischemic stroke. He is unresponsive and completely lacks decision-making capacity. The primary care team determines that a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube will be necessary if life-prolonging measures are to be continued. Multiple individuals arrive at the hospital, each claiming the right to make medical decisions on the patient's behalf. Arrange the following potential decision-makers from highest priority (first) to lowest priority (last) according to the standard legal hierarchy of surrogate decision-makers.

A 60-year-old female patient is transferred to the critical care unit due to acute respiratory failure caused by viral pneumonia. She requires mechanical ventilation, is deeply sedated, and lacks decision-making capacity. Medical records indicate she does not have an advance directive or a legally designated healthcare proxy. As her condition worsens, the critical care team must obtain consent for extracorporeal membrane oxygenation (ECMO). Multiple relatives are present at the bedside, each expressing a willingness to direct her medical care. According to the standard legal hierarchy for surrogate decision-makers, arrange the following individuals in the correct sequence of priority to provide informed consent, from highest priority (first) to lowest priority (last).

A 6-year-old boy is brought to the pediatric emergency department with a 2-day history of high fever, severe headache, and progressively worsening lethargy. His parents recently immigrated, and his immunization status is unknown. Temperature is 39.8°C (103.6°F), blood pressure is 112/72 mmHg, pulse is 135/min, and respiratory rate is 24/min. On physical examination, the child is somnolent but arousable to painful stimuli. Marked nuchal rigidity is present. Neurologic examination reveals a sluggish left pupillary reflex and right-sided pronator drift. Arrange the following steps in the most appropriate sequential order for the acute management of this patient.

A 58-year-old man presents to the emergency department with acute-onset, crushing substernal chest pain radiating to his left jaw that began 45 minutes ago. He is diaphoretic and appears distressed. Vital signs show a blood pressure of 145/90 mm Hg and a heart rate of 92/min. Arrange the following steps in the most appropriate chronological order for the initial diagnosis and definitive management of this patient's condition.

A 64-year-old man arrives at the emergency department reporting the abrupt onset of severe, tearing chest pain that radiates between his shoulder blades. His blood pressure is 210/120 mmHg in the right arm and 180/100 mmHg in the left arm, with a heart rate of 118/min. Physical examination reveals a new diastolic decrescendo murmur at the right upper sternal border. An acute aortic dissection is highly suspected. Arrange the following steps in the most appropriate clinical sequence for the evaluation and management of this patient.

A 45-year-old man with a history of intravenous drug use presents to the hospital with a 5-day history of severe chills, fatigue, and high fevers. On physical examination, his temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is 112/min, and blood pressure is 118/76 mm Hg. Cardiac auscultation reveals a newly documented holosystolic murmur prominent at the lower left sternal border. Cutaneous examination demonstrates painful, violaceous nodules on the pads of his fingers. Suspecting acute infective endocarditis, arrange the following clinical management steps in the correct chronological sequence according to standard guidelines.

A $68$-year-old man is evaluated for progressive shortness of breath, fatigue, and bilateral lower extremity swelling over the past $6$ months. He also reports numbness and tingling in both hands, for which he underwent bilateral carpal tunnel release surgery last year. Blood pressure is $110/70 \text{ mmHg}$, and pulse is $85 \text{ /min}$. Physical examination reveals elevated jugular venous pressure with prominent x and y descents, clear lungs, and $2+$ pitting edema in the lower extremities. An electrocardiogram shows low voltage in the limb leads. A transthoracic echocardiogram demonstrates severe left ventricular concentric thickening, a granular "sparkling" appearance of the myocardium, biatrial enlargement, and a preserved left ventricular ejection fraction of $60\%$. A diagnosis of cardiac amyloidosis is suspected.

Arrange the following diagnostic and management steps in the most appropriate chronological sequence for evaluating and treating this patient's condition.

Following a presentation of severe, bilateral lower pelvic pain and high-grade fever ($38.9^\circ\text{C}$), a $32$-year-old female is evaluated in the emergency department. She reports having a copper intrauterine device (IUD) inserted four years prior. On physical examination, marked cervical motion tenderness and purulent cervical exudate are noted. Pelvic ultrasonography confirms the IUD is properly situated within the endometrial cavity and reveals bilateral fallopian tube thickening consistent with severe pelvic inflammatory disease (PID), but no tubo-ovarian abscess is visualized. The patient is admitted to the inpatient ward for complicated PID.

Arrange the following diagnostic and therapeutic interventions in the most appropriate chronological sequence according to current clinical guidelines.

A 40-year-old woman asks about her future risk of developing breast cancer after undergoing a core needle biopsy for a mammographic abnormality. Arrange the following potential histopathologic biopsy results in order from the LOWEST to the HIGHEST risk for the subsequent development of invasive breast cancer.

An otherwise healthy 42-year-old female patient is evaluated in the urogynecology clinic for bothersome urinary leakage. She notes that the involuntary loss of urine occurs exclusively during physical exertion, specifically when she jogs, coughs, or sneezes. She experiences no dysuria, nocturia, or sudden overwhelming urges to urinate. A recently completed voiding diary confirms leakage tied entirely to physical activity. During the physical examination, a cough stress test demonstrates immediate, brief fluid loss from the urethra. The patient is highly motivated to improve her symptoms and asks to discuss all available treatment modalities. She prefers a stepwise approach, starting with the safest, non-invasive therapies before considering any surgical interventions.

Arrange the following management strategies for this patient's condition in the standard clinical sequence, escalating from initial first-line therapy to definitive surgical options for complex cases.

A 32-year-old G2P2 at $39$ weeks gestation experiences significant vaginal bleeding immediately after the vaginal delivery of a $4100$ g neonate. The intrapartum fetal heart rate tracing was Category I. The placenta delivers spontaneously and appears intact. On examination, her blood pressure is $90/55$ mmHg and heart rate is $115$/min. The uterus is soft, boggy, and palpated above the umbilicus. Arrange the following interventions in the most appropriate sequential order for the management of this patient's postpartum hemorrhage, progressing from the initial step to the final definitive treatment.

A 29-week gestation female neonate develops grunting, nasal flaring, and intercostal retractions shortly after birth. She is diagnosed with Neonatal Respiratory Distress Syndrome (RDS). Arrange the following pathophysiologic events in the correct chronological sequence that ultimately leads to the classic histopathologic findings of this condition.

A 24-hour-old term male neonate is evaluated in the nursery for rapidly progressing jaundice. He was born via uncomplicated vaginal delivery at 39 weeks gestation to a mother with blood type O, Rh-positive. His birth weight was $3400\text{ g}$. APGAR scores were 8 and 9 at 1 and 5 minutes, respectively. The infant's blood type is A, Rh-positive, and his direct antiglobulin test (DAT) is strongly positive. He is currently vigorous and feeding well with breast milk. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate is $145\text{/min}$, and respiratory rate is $42\text{/min}$. Arrange the following interventions in the most appropriate escalating sequence for the management of this patient's condition, assuming continued clinical deterioration and refractoriness to each preceding therapy.

A healthy 41-year-old female arrives at the surgical assessment unit complaining of steady pain under her right rib cage that began shortly after eating a heavy meal. Examination reveals localized tenderness and inspiratory arrest upon deep palpation in the right upper quadrant. Her temperature is 38.2°C (100.8°F) and vital signs are otherwise stable. Arrange the following interventions in the most appropriate chronological sequence for her standard evaluation and definitive care.

A 58-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 back. His blood pressure is 210/115 mmHg in the right arm and 170/90 mmHg in the left arm. His pulse is 112/min. Physical examination reveals a new diastolic decrescendo murmur at the right sternal border. An electrocardiogram shows sinus tachycardia with no ischemic changes, and a chest x-ray reveals a widened mediastinum. Arrange the following management steps in the most appropriate chronological sequence for this patient.